Nokea
The nurse is assessing a client in labor and notes persistent late decelerations on the monitor. What is the priority action?
- A. Reposition the client to her left side.
- B. Administer oxygen via face mask.
- C. Increase IV fluids.
- D. Notify the healthcare provider.
Correct Answer: A
Rationale: The correct answer is A: Reposition the client to her left side. This is the priority action because late decelerations indicate uteroplacental insufficiency, possibly due to compression of the umbilical cord. Repositioning the client to her left side can help improve blood flow to the placenta by reducing pressure on the vena cava, thus optimizing fetal oxygenation. Administering oxygen (B) is important but not the immediate priority. Increasing IV fluids (C) may not directly address the cause of late decelerations. Notifying the healthcare provider (D) is important but should come after immediate interventions.
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How can a nurse best prevent heat loss in a newborn during the first hour of life?
- A. Place the newborn under a radiant warmer
- B. Dry the newborn and cover with a warm blanket
- C. Place the newborn in a skin-to-skin position with the mother
- D. Keep the newborn wrapped in a wet blanket
Correct Answer: A
Rationale: The correct answer is A: Place the newborn under a radiant warmer. This method is the most effective in preventing heat loss in a newborn as radiant warmers provide a consistent heat source to maintain the newborn's body temperature. This is crucial during the first hour of life when newborns are at a higher risk of hypothermia.
Choice B is not as effective as using a radiant warmer as it may not provide enough warmth to prevent heat loss. Choice C, placing the newborn in a skin-to-skin position with the mother, is beneficial for bonding and regulating the newborn's temperature in the long term but may not be as effective as a radiant warmer in the immediate post-birth period.
Choice D, keeping the newborn wrapped in a wet blanket, is incorrect as wet blankets can further contribute to heat loss through evaporative cooling. In summary, using a radiant warmer is the best option for preventing heat loss in a newborn during the critical first hour of life.
What is a statement that best describes reproductive health?
- A. Reproductive health focuses solely on the ability to reproduce and have children.
- B. Reproductive health encompasses physical well-being but does not include mental and social aspects.
- C. Reproductive health involves complete physical, mental, and social well-being related to the reproductive system.
- D. Reproductive health is limited to making informed decisions about contraception methods.
Correct Answer: C
Rationale: The correct answer is C because reproductive health is not just about the ability to reproduce but also includes mental and social well-being. This choice aligns with the World Health Organization's definition of reproductive health, which emphasizes holistic well-being. Choice A is incorrect as it oversimplifies reproductive health. Choice B is incorrect because reproductive health should address all aspects of well-being. Choice D is incorrect as reproductive health goes beyond just contraception to encompass a broader scope of health and well-being.
Which intervention should the nurse prioritize for a pregnant client with placenta previa?
- A. Monitor the client for contractions
- B. Prepare for immediate cesarean delivery
- C. Monitor for signs of fetal distress
- D. Encourage the client to remain in bed rest
Correct Answer: B
Rationale: The correct answer is B: Prepare for immediate cesarean delivery. Placenta previa is a condition where the placenta partially or completely covers the cervix, which can lead to life-threatening bleeding during labor. Immediate cesarean delivery is the priority to prevent maternal and fetal complications. Monitoring for contractions (A) is important but not the priority. Monitoring for fetal distress (C) is crucial but not the immediate intervention. Encouraging bed rest (D) may be recommended but is not the priority intervention in placenta previa.
Which statement by the client would alert the nurse that she should not take oral contraceptives?
- A. I drink one to two alcohol drinks a few times a week.
- B. I am slightly overweight and have a difficult time fitting exercise into my schedule.
- C. I am trying to limit cigarettes to one pack a week.
- D. I try to have my boyfriend wear a condom every time we have sex.
Correct Answer: C
Rationale: The correct answer is C because smoking while taking oral contraceptives increases the risk of blood clots, stroke, and heart attack. Smoking and oral contraceptives together pose a higher risk than either alone. Choices A, B, and D are not direct contraindications for taking oral contraceptives. A: Moderate alcohol consumption is generally not contraindicated. B: Being slightly overweight and having difficulty with exercise are not absolute contraindications. D: Using condoms is a good practice but does not specifically indicate a reason not to take oral contraceptives.
A client at 12 weeks' gestation asks about the purpose of nuchal translucency testing. What is the nurse's best response?
- A. It screens for fetal anemia.
- B. It detects neural tube defects.
- C. It screens for chromosomal abnormalities.
- D. It confirms gestational age.
Correct Answer: C
Rationale: The correct answer is C because nuchal translucency testing is primarily used to screen for chromosomal abnormalities, such as Down syndrome, in the fetus. This test measures the thickness of the fluid-filled space at the back of the baby's neck. It is typically done between 11 and 14 weeks of pregnancy. This testing helps to assess the risk of genetic conditions in the fetus. Option A is incorrect because nuchal translucency testing does not screen for fetal anemia. Option B is incorrect because it does not detect neural tube defects. Option D is incorrect because it does not confirm gestational age.