Nokea
The nurse is assessing a client with suspected preterm labor. Which finding confirms the diagnosis?
- A. Regular uterine contractions every 10 minutes.
- B. Cervical dilation of 3 cm.
- C. Lower back pain and cramping.
- D. Positive fetal fibronectin test.
Correct Answer: B
Rationale: The correct answer is B: Cervical dilation of 3 cm. This finding confirms preterm labor as it indicates cervical changes associated with labor progression. Regular uterine contractions every 10 minutes (choice A) may suggest labor but alone doesn't confirm preterm labor. Lower back pain and cramping (choice C) are common symptoms but not specific to preterm labor. A positive fetal fibronectin test (choice D) may indicate an increased risk of preterm labor but doesn't confirm the diagnosis definitively.
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The nurse is aware that a pre-term neonate may have a potential nutritional problem because of:
- A. Poor sucking reflex
- B. A decreased metabolic rate
- C. Decreased caloric requirement
- D. Increased absorption of nutrients
Correct Answer: A
Rationale: The correct answer is A: Poor sucking reflex. Pre-term neonates often have immature sucking reflexes, which can lead to difficulty in feeding and obtaining adequate nutrition. This can result in a potential nutritional problem. Option B is incorrect because pre-term neonates actually have an increased metabolic rate to support their growth and development. Option C is incorrect as pre-term neonates have increased caloric requirements due to their rapid growth. Option D is incorrect as pre-term neonates typically have decreased absorption of nutrients due to an immature gastrointestinal system.
A nurse is assessing a client who is 3 days postpartum and is breastfeeding. The nurse notes that the fundus is three fingerbreadths below the umbilicus, lochia rubra is moderate, and the breasts are hard and warm to palpation. Which of the following interpretations of these findings should the nurse make?
- A. The client is exhibiting early indications of mastitis.
- B. Additional interventions are not indicated at this time.
- C. Application of a heating pad to the breasts is indicated.
- D. The client should be advised to remove her nursing bra.
Correct Answer: B
Rationale: Correct Answer: B - Additional interventions are not indicated at this time.
Rationale:
1. Fundus location: Three fingerbreadths below the umbilicus is within normal range for 3 days postpartum.
2. Lochia rubra: Moderate lochia rubra is expected at this stage postpartum.
3. Breasts: Hard and warm breasts are indicative of engorgement, a common issue in breastfeeding mothers.
Summary:
A: Early indications of mastitis would include redness, warmth, and tenderness in the breasts, along with flu-like symptoms.
C: Application of a heating pad to the breasts can worsen engorgement and increase the risk of mastitis.
D: Removing a nursing bra may offer some relief for engorgement, but it is not the priority intervention at this time.
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.
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.
After several hours of labor, the fetal heart monitor shows
- A. The nurse would interpret this deceleration to be consistent with which presentation?
- B. Umbilical cord compression
- C. Uteroplacental insufficiency
- D. Compression of fetal head
Correct Answer: B
Rationale: The correct answer is B: Umbilical cord compression. When the fetal heart monitor shows deceleration after several hours of labor, it indicates reduced oxygen supply to the fetus. Umbilical cord compression can restrict blood flow and oxygen delivery to the fetus, leading to decelerations. This is a common cause during labor. Choices A, C, and D do not directly relate to the decreased oxygen supply indicated by decelerations on the fetal heart monitor.