Nokea
The nurse is assessing a client who reports vaginal bleeding at 20 weeks' gestation. What is the priority action?
- A. Assess the amount and color of bleeding.
- B. Place the client in a Trendelenburg position.
- C. Administer Rho(D) immune globulin.
- D. Perform a vaginal examination.
Correct Answer: A
Rationale: Assessing the bleeding provides critical information to determine the next steps and evaluate potential complications.
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A client in labor receiving an epidural reports feeling lightheaded and nauseous. What is the nurse's priority intervention?
- A. Administer antiemetics as prescribed.
- B. Check maternal blood pressure.
- C. Increase the oxytocin infusion rate.
- D. Encourage the client to lie on her back.
Correct Answer: B
Rationale: Lightheadedness and nausea can be signs of hypotension, a common side effect of epidural anesthesia.
A pregnant client tells the clinic nurse she wants to know the sex of her baby as soon as it can be determined. What factor allows this at 12 weeks' gestation?
- A. The appearance of the fetal external genitalia
- B. The beginning of differentiation in the fetal groin
- C. The fetal testes are descended into the scrotal sac
- D. The internal differences in males and females become apparent
Correct Answer: A
Rationale: By 12 weeks, the external genitalia are sufficiently developed for visual determination of the baby's sex.
What is the primary nursing concern for a mother receiving magnesium sulfate therapy?
- A. Monitor blood pressure every 4 hours
- B. Monitor deep tendon reflexes hourly
- C. Assess respiratory rate and effort
- D. Prepare for delivery if signs of toxicity appear
Correct Answer: B
Rationale: Monitoring reflexes detects early signs of magnesium toxicity.
A pregnant woman tells the nurse-midwife, 'I've heard that if I eat certain foods during my pregnancy, the baby will be a boy.' The nurse-midwife should explain that this is a myth, and that the sex of the baby is determined at what time?
- A. At the time of ejaculation
- B. At the time of fertilization
- C. At the time of implantation
- D. At the time of differentiation
Correct Answer: B
Rationale: The sex of a baby is determined at fertilization. Sperm cells carry either an X or Y chromosome, while the ovum only carries an X chromosome. If the sperm contributes an X chromosome, the baby will be female, and if it contributes a Y chromosome, the baby will be male.
The nurse is caring for a client in labor with an epidural. What assessment is most important immediately after placement?
- A. Monitor maternal temperature.
- B. Assess for lower extremity weakness.
- C. Monitor maternal blood pressure.
- D. Check fetal presentation.
Correct Answer: C
Rationale: Maternal blood pressure monitoring is essential to detect and manage hypotension caused by epidural anesthesia.