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A patient vaginally delivered an infant at 4750 g moderate shoulder dystocia occurred during the birth. During the initial assessment of the infant the nurse should look for
- A. Erb's palsy
- B. Bell palsy
- C. Bradycardia
- D. Petechiae
Correct Answer: C
Rationale: The correct answer is C: Bradycardia. During shoulder dystocia, the infant may experience umbilical cord compression leading to decreased oxygen supply and potential bradycardia. Bradycardia is a critical sign that requires immediate attention. Erb's palsy (A) is a brachial plexus injury due to shoulder dystocia, not an immediate concern. Bell palsy (B) is a facial nerve paralysis unrelated to birth trauma. Petechiae (D) are small red or purple spots that may indicate bleeding disorders but are not specific to shoulder dystocia.
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What hormone is responsible for the development and maturation of the ovarian follicles?
- A. follicle-stimulating hormone (FSH)
- B. luteinizing hormone (LH)
- C. estrogen
- D. progesterone
Correct Answer: A
Rationale: Rationale: Follicle-stimulating hormone (FSH) is responsible for the development and maturation of ovarian follicles by stimulating them to grow and produce estrogen. FSH plays a crucial role in the menstrual cycle and acts on the ovaries to promote follicular development. LH surge triggers ovulation, estrogen is produced by the developing follicles and progesterone is primarily produced after ovulation by the corpus luteum. Therefore, A is correct as it directly influences the growth and maturation of ovarian follicles.
A client at 37 weeks' gestation reports swollen feet and hands. What assessment finding requires immediate intervention?
- A. Blood pressure of 150/95 mmHg.
- B. Weight gain of 1 pound in a week.
- C. Mild nausea after eating.
- D. Fetal movements are regular.
Correct Answer: A
Rationale: The correct answer is A: Blood pressure of 150/95 mmHg. This finding indicates gestational hypertension, which can progress to preeclampsia, a serious condition that requires immediate intervention to prevent complications for both the mother and baby. High blood pressure can lead to organ damage and placental insufficiency.
B: Weight gain of 1 pound in a week is within the normal range for late pregnancy and may not require immediate intervention.
C: Mild nausea after eating is a common pregnancy symptom and does not indicate an urgent issue.
D: Regular fetal movements are a positive sign of fetal well-being and do not require immediate intervention.
Developing a plan to achieve patient outcomes is included in which step of the CJMM?
- A. prioritizing hypotheses
- B. generating solutions
- C. taking action
- D. evaluating outcomes
Correct Answer: B
Rationale: The correct answer is B: generating solutions. In the CJMM (Clinical Judgment Model in Nursing), developing a plan to achieve patient outcomes falls under the step of generating solutions. This step involves identifying and implementing interventions to address the patient's needs and achieve the desired outcomes. Prioritizing hypotheses (A) is about identifying potential issues, not developing a plan. Taking action (C) is about implementing the plan, not developing it. Evaluating outcomes (D) is the final step where the effectiveness of the plan is assessed, not where the plan is developed. Therefore, B is the correct choice as it specifically focuses on the process of creating a plan to achieve patient outcomes within the CJMM.
The nurse is assessing a client with suspected placenta previa. Which finding supports this diagnosis?
- A. Painful, bright red bleeding.
- B. Painless, bright red bleeding.
- C. Hard, rigid abdomen.
- D. Decreased fetal movements.
Correct Answer: B
Rationale: The correct answer is B: Painless, bright red bleeding. Placenta previa is characterized by painless vaginal bleeding due to the placenta covering the cervical os. Bright red blood indicates fresh bleeding from the lower uterus. This finding supports the diagnosis as it aligns with the classic presentation of placenta previa.
A: Painful, bright red bleeding is not characteristic of placenta previa, as the bleeding is usually painless.
C: A hard, rigid abdomen is more indicative of a uterine rupture or abruption, not placenta previa.
D: Decreased fetal movements are not directly associated with placenta previa; this finding may suggest fetal distress but is not specific to this condition.
The nurse is monitoring a client with hypertonic uterine contractions. What is the priority nursing action?
- A. Administer pain relief as prescribed.
- B. Prepare for an amniotomy.
- C. Encourage ambulation.
- D. Increase oxytocin infusion.
Correct Answer: A
Rationale: The correct answer is A: Administer pain relief as prescribed. The priority is to address the client's discomfort and pain caused by hypertonic uterine contractions. Pain management is crucial to ensure the client's comfort and well-being. Administering pain relief can help prevent complications such as increased stress on the mother and fetus.
Choice B: Prepare for an amniotomy is incorrect because it involves artificial rupturing of the amniotic sac, which is not indicated for hypertonic contractions.
Choice C: Encourage ambulation is incorrect because it may exacerbate the pain and discomfort experienced by the client with hypertonic uterine contractions.
Choice D: Increase oxytocin infusion is incorrect because it can further intensify the uterine contractions and worsen the client's pain.