Nokea
The nurse has taken a health history on four primigravid clients at their first prenatal visits. It is high priority that which of the clients receives nutrition counseling?
- A. The woman diagnosed with phenylketonuria.
- B. The woman who has Graves’ disease.
- C. The woman with Cushing’s syndrome.
- D. The woman diagnosed with myasthenia gravis.
Correct Answer: A
Rationale: Phenylketonuria (PKU) requires strict dietary management, especially during pregnancy, to prevent harm to the fetus. The other conditions do not have the same immediate dietary implications.
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Can the baby's sex be determined at 8 weeks' gestation?
- A. Doctor knows the sex
- B. Organs are formed but too small
- C. Technician sees a penis
- D. It will take another month
Correct Answer: D
Rationale: At 8 weeks, organs are developing but too small to determine sex; this usually occurs around 18–20 weeks.
A 16-year-old, G1 P0000, is being seen at her 10-week gestation visit. She tells the nurse that she felt the baby move that morning. Which of the following responses by the nurse is appropriate?
- A. That is very exciting. The baby must be very healthy.
- B. Would you please describe what you felt for me?
- C. That is impossible. The baby is not big enough yet.
- D. Would you please let me see if I can feel the baby?
Correct Answer: B
Rationale: At 10 weeks, fetal movement is unlikely to be felt. The nurse should ask the client to describe what she felt to determine if it was indeed fetal movement or another sensation.
A nurse is assisting a laboring person who is in the first stage of labor. What is the most appropriate intervention to promote relaxation and comfort?
- A. encourage ambulation
- B. administer pain medication
- C. provide distraction and breathing techniques
- D. offer relaxation techniques
Correct Answer: A
Rationale: The correct answer is A: encourage ambulation. Walking during the first stage of labor can help facilitate the descent of the fetus, promote optimal positioning, and enhance comfort by utilizing gravity to aid in the progression of labor. Ambulation also encourages blood circulation and may provide a distraction from discomfort. Administering pain medication (B) is not the initial intervention in promoting relaxation and comfort during early labor. Providing distraction and breathing techniques (C) may be beneficial, but ambulation is more effective in promoting relaxation. Offering relaxation techniques (D) is helpful, but encouraging movement through ambulation is a more active approach in easing discomfort and promoting relaxation during the first stage of labor.
What is the purpose of performing an amniotomy during labor?
- A. to induce labor and promote cervical dilation
- B. to reduce the risk of infection
- C. to augment labor and prevent prolonged labor
- D. to prevent fetal infection
Correct Answer: C
Rationale: Performing an amniotomy during labor is done to augment labor by releasing amniotic fluid, which can help progress labor by increasing uterine contractions and encouraging the descent of the baby's head. This can help prevent prolonged labor and facilitate a smoother delivery process. Options A, B, and D are incorrect because inducing labor, reducing the risk of infection, and preventing fetal infection are not the primary purposes of performing an amniotomy.
A woman who is 25 weeks pregnant asks the nurse what her fetus looks like. What does the nurse explain is one physical characteristic present in a 25-week-old fetus?
- A. Lanugo covering the body
- B. Constant motion
- C. Skin that is pink and smooth
- D. Eyes that are closed
Correct Answer: A
Rationale: By 25 weeks, the body of the fetus is covered with lanugo, the eyes are open, the skin is wrinkled, and the fetus has definite periods of movement and sleeping.