Nokea
The nurse is assessing the client for the presence of ballottement. Which should the nurse perform to test for the presence of ballottement?
- A. Palpate the uterus for contractions
- B. Assess the skin for increased pigmentation
- C. Initiate a gentle upward tap on the cervix
- D. Palpate the abdomen for fetal outline
Correct Answer: C
Rationale: The correct answer is C. To test for the presence of ballottement, the nurse should initiate a gentle upward tap on the cervix. Ballottement is a technique used in obstetrics to assess for the presence of a floating object in the uterus, such as a fetus. By tapping the cervix gently, the nurse can feel for a rebound effect, indicating the presence of a floating object. This technique helps to confirm the presence of a fetus in the uterus.
Explanation of why other choices are incorrect:
A: Palpating the uterus for contractions is not relevant to testing for ballottement.
B: Assessing the skin for increased pigmentation is not related to assessing for the presence of a floating object in the uterus.
D: Palpating the abdomen for fetal outline does not specifically test for ballottement, which involves tapping the cervix.
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An emergency cesarean is being implemented. The patient describes tingling in her ears and a metallic taste with the administration of regional anesthesia. The nurse is aware that which incidence has occurred?
- A. Manifestation of maternal respiratory depression related to anesthesia
- B. Inadvertent injection of the anesthetic agent into the maternal bloodstream
- C. Maternal hypotension is occurring related to administration of anesthesia
- D. Expected manifestations related to anesthetic medications are present
Correct Answer: B
Rationale: The correct answer is B: Inadvertent injection of the anesthetic agent into the maternal bloodstream. This is indicated by the patient experiencing tingling in her ears and a metallic taste, which are signs of systemic toxicity from the anesthetic agent. The anesthetic has entered the bloodstream instead of staying localized to the intended area. Other choices are incorrect as A is more related to opioid overdose, C is more related to hypotension, and D implies that these symptoms are normal when they are not.
A nurse is taking a birth history assessment on a client who is 8 weeks gestation and has one child who was born at 38 weeks. Which is consistent with this birth history?
- A. Primipara
- B. Primigravida
- C. Nulligravida
- D. Multipara
Correct Answer: D
Rationale: The correct answer is D: Multipara. This term refers to a woman who has given birth to two or more children. In this case, the client has one child already, making her a multipara.
A: Primipara refers to a woman who has given birth to one child, which does not match the client's birth history.
B: Primigravida refers to a woman who is pregnant for the first time, which also does not match the client's history.
C: Nulligravida refers to a woman who has never been pregnant, which is not the case for the client.
Therefore, the correct term to describe the client's birth history is Multipara, as she has one child and is currently 8 weeks gestation.
Decreased capillary refill, delay in milk production, and diminished peripheral pulses are signs of what complication?
- A. alteration in perfusion
- B. alteration in liver function
- C. alteration in kidney function
- D. alteration in uterine function
Correct Answer: C
Rationale: The correct answer is C, alteration in kidney function. Decreased capillary refill indicates poor perfusion due to impaired kidney function leading to reduced blood flow. Delay in milk production is not directly related to kidney or liver function. Diminished peripheral pulses can be a sign of decreased blood flow due to kidney dysfunction affecting circulation. Alteration in liver or uterine function would not typically present with these specific signs. Therefore, the signs listed are most indicative of a complication related to kidney function.
When assessing a prenatal client at follow-up prenatal visits during the second trimester, the nurse should anticipate which assessments to be performed at each visit? Select all that apply.
- A. Cervical examination
- B. Weight, height, BMI
- C. Fetal ultrasound
- D. Fundal height
Correct Answer: B
Rationale: The correct answer is B: Weight, height, BMI. During each second-trimester prenatal visit, it is essential to monitor the client's weight, height, and BMI to ensure appropriate maternal and fetal health. Weight gain is a crucial indicator of fetal growth and maternal well-being. Height and BMI can provide insights into the client's nutritional status and overall health.
Explanation of why other choices are incorrect:
A: Cervical examination is typically not performed routinely during second-trimester prenatal visits unless there are specific concerns such as preterm labor risk.
C: Fetal ultrasound is usually scheduled at specific times during pregnancy, not necessarily at every second-trimester visit.
D: Fundal height measurement is important, but it is usually performed starting in the second trimester to assess fetal growth and position, not necessarily at every visit.
The nurse is concerned that a patient’s uterine activity is too intense and that her obesity is
preventing accurate assessment of the actual intrauterine pressure. Based on this information,
which action should the nurse take?
- A. Reposition the tocotransducer.
- B. Reposition the Doppler transducer.
- C. Obtain an order from the health care provider for a spiral electrod
- D. Obtain an order from the health care provider for an intrauterine pressure catheter.
Correct Answer: D
Rationale: The correct answer is D: Obtain an order from the health care provider for an intrauterine pressure catheter. This is the most appropriate action because an intrauterine pressure catheter provides the most accurate assessment of intrauterine pressure, especially in cases where obesity may interfere with external monitoring methods. Repositioning the tocotransducer (choice A) or Doppler transducer (choice B) may not significantly improve accuracy in this situation. Obtaining an order for a spiral electrod (choice C) is not necessary as it does not directly address the issue of accurate intrauterine pressure assessment.