Nokea
A nurse is teaching a prenatal class regarding false labor. Which of the following information should the nurse include?
- A. "Your contraction will become more intense when walking"
- B. "You will have dilation and effacement of the cervix"
- C. You will have bloody show"
- D. "Your contraction will become temporally regular"
Correct Answer: D
Rationale: False labor, also known as Braxton Hicks contractions, are contractions that are irregular and do not lead to cervical dilation and effacement, unlike true labor contractions. During false labor, contractions may feel intense when walking, but they do not become progressively more intense over time, as is seen in true labor. Additionally, false labor contractions do not typically result in bloody show, which is a sign of impending true labor. Therefore, the correct information to include regarding false labor is that contractions will remain temporarily irregular in nature.
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During the first few minutes after birth which physiologic changes occurs in the newborn as response to vascular pressure changes in increased oxygen levels?
- A. Dilation of pulmonary vessel (dilation of pulmonary vessels occurs in response to increased oxygen levels)
Correct Answer: A
Rationale: Immediately after birth, as the newborn takes its first breaths and transitions to breathing air, there is a rapid increase in oxygen levels in the blood. This sudden increase in oxygen causes the pulmonary vessels in the newborn's lungs to dilate. This dilation helps improve blood flow through the lungs, allowing for efficient exchange of oxygen and carbon dioxide. The dilation of pulmonary vessels is a normal physiologic response to the changing environment in the newborn's body after birth.
A nurse is admitting a client who is at 35 weeks of gestation and is experiencing mild vaginal bleeding due to placenta previa. Which of the following actions should the nurse plan to take?
- A. Initiate continuous monitoring of the FHR.
- B. Administer a dose of betamethasone.
- C. Check the cervix for dilation every 8 hr.
- D. Request that the provider prescribe misoprostol PRN.
Correct Answer: A
Rationale: In placenta previa, the placenta partially or completely covers the cervix, which can lead to vaginal bleeding. Continuous monitoring of the fetal heart rate (FHR) is crucial in this situation to assess the well-being of the fetus. Any signs of distress or changes in the FHR can indicate potential complications, such as fetal hypoxia. This monitoring allows for prompt intervention if necessary to ensure the safety of both the mother and the baby. Administering betamethasone may be indicated to promote fetal lung maturity in cases of anticipated preterm birth, but it is not the priority in this scenario where monitoring the fetal well-being is crucial. Checking the cervix for dilation every 8 hours is not necessary and may increase the risk of further bleeding. Misoprostol, a medication used to induce labor, is contraindicated in cases of placenta previa because it can cause further
What is the nurse's role in supporting breastfeeding for a first-time mother?
- A. Provide formula supplements
- B. Demonstrate proper latching techniques
- C. Recommend stopping breastfeeding
- D. Provide pacifiers to prevent overfeeding
Correct Answer: A
Rationale: Proper latching techniques help establish successful breastfeeding and prevent complications.
A neonate born at 34 weeks' gestation and weighing 6lbs, 10oz (2750g) is admitted to the nursery, The vital signs are: apical heart rate 130; respiration 58, BP- 60/20. Temp. 98 degrees F; Apgar score of 4 and 8. The nurse should designate the highest priority health outcomes to be:
- A. Oxygenation will remain adequate
- B. Body temperature will remain stable
- C. Weight will increase by 30g per day
- D. Heart rate will recover to an acceptable range
Correct Answer: A
Rationale: Oxygenation is critical for pre-term infants.
During the assessment of a newborn, it is most important for the nurse to report a:
- A. Temperature of 97.7 degrees Fahrenheit
- B. Pale pink, rust-colored stain in the diaper
- C. Heart rate that drops to 120 beats/min
- D. Breathing pattern that is diaphragmatic with sternal retractions
Correct Answer: D
Rationale: Sternal retractions indicate respiratory difficulty.