Nokea
The nurse is assessing a client at 36 weeks' gestation who reports swelling in the hands and face. What is the priority nursing action?
- A. Check the client’s blood pressure.
- B. Reassure the client that swelling is normal.
- C. Encourage the client to reduce salt intake.
- D. Evaluate the fetal heart rate.
Correct Answer: A
Rationale: Swelling in the hands and face may indicate preeclampsia, requiring immediate blood pressure assessment.
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Positive signs of pregnancy
- A. FHR detected by electronic doppler @10-12 wks
- B. Active fetal movements palpable by examiner
- C. Outline of fetus by radiography or ultrasound
Correct Answer: B
Rationale: One of the positive signs of pregnancy is the active fetal movements palpable by the examiner. This occurs when the examiner is able to feel the movements of the fetus inside the uterus. This sign usually becomes noticeable in the second half of pregnancy and is a clear indication that the pregnancy is progressing normally. It is a reassuring sign for both the pregnant individual and the healthcare provider that the fetus is active and healthy.
What cycle day does the proliferative stage occur?
- A. Cycle day 7-14
- B. Cycle day 14-28
- C. Cycle day 1-6
- D. Cycle day 1-14
Correct Answer: A
Rationale: The proliferative stage of the menstrual cycle occurs from around cycle day 7 to cycle day 14. This stage is characterized by the growth of the endometrial lining of the uterus in response to increasing levels of estrogen produced by the developing ovarian follicles. The proliferative stage prepares the uterus for a potential embryo implantation following ovulation, which typically occurs around day 14 of a 28-day menstrual cycle.
A nurse is caring for a client who is in labor and has an external fetal monitor. The nurse observes late decelerations on the monitor strip and interprets them as indicating which of the following?
- A. Uteroplacental insufficiency
- B. Maternal bradycardia
- C. Umbilical cord compression
- D. Fetal head compression
Correct Answer: A
Rationale: Late decelerations on the fetal monitor strip indicate uteroplacental insufficiency. These decelerations occur after the peak of a contraction, and the fetus may not receive enough oxygen-rich blood during contractions. Uteroplacental insufficiency can lead to fetal hypoxia and acidosis if not addressed promptly. It is important for the nurse to take appropriate steps to improve fetal oxygenation, such as repositioning the mother, administering oxygen, and adjusting IV fluids. If late decelerations persist, further interventions may be necessary to ensure the well-being of the fetus.
The nurse is explaining how a newly delivered baby initiates respiration. Which statement explains this process?
- A. Chemical thermal and mechanical factors
- B. Increase of po2 and decreased pco2
- C. Continued function of foramen ovale
- D. Drying off the infant
Correct Answer: A
Rationale: The correct statement explaining how a newly delivered baby initiates respiration is "Chemical thermal and mechanical factors." When a baby is born, various factors come into play to stimulate the baby's first breath. Chemically, the baby senses a decrease in oxygen and an increase in carbon dioxide levels, triggering the respiratory centers in the brain to start the breathing process. Thermally, exposure to the cooler air outside the womb stimulates the baby's skin receptors, encouraging the baby to take a breath. Mechanically, the pressure changes during delivery and the physical stimulation of the baby's face and body also play a role in initiating respiration. Overall, it is the combined effect of these chemical, thermal, and mechanical factors that help a newly delivered baby begin breathing independently.
Multiparous patient admitted to labor unit with regular contractions 2 minutes apart and last 60 seconds. She reports labor began 6 hours ago and she had bloody show earlier this morning.The patient asks what stage of labor she is in
- A. Transition phase
- B. Active phase
- C. Latent phase
- D. Second stage
Correct Answer: B
Rationale: Based on the information provided, the patient is experiencing regular contractions 2 minutes apart lasting 60 seconds, and she had a bloody show earlier in the morning. These signs in a multiparous patient with 6 hours of labor indicate she is most likely in the transition phase of labor. The transition phase is characterized by intense contractions that are closer together, typically 2-3 minutes apart, and lasting longer, usually around 60-90 seconds. This stage signifies the progression towards the final stages of labor, leading up to the pushing stage and delivery. Therefore, the correct answer is B, Transition phase.