Nokea
The nurse is caring for a client and her partner who just birthed a 33-week fetal demise. Which of the following actions by the nurse is appropriate at this time?
- A. Recommend that the woman be moved to a medical unit.
- B. Refrain from discussing the loss with the couple.
- C. Ask the couple if they would like to hold their baby.
- D. Obtain an order for a milk suppressant for the mother.
Correct Answer: C
Rationale: Allowing the couple to hold their baby facilitates the grieving process and provides closure.
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Which aspect of fetal diagnostic testing is most important to expectant parents?
- A. Safety of the fetus
- B. Duration of the test
- C. Cost of the procedure
- D. Physical discomfort caused by the procedure
Correct Answer: A
Rationale: The correct answer is A: Safety of the fetus. Expectant parents prioritize the safety of their unborn child above all else. Ensuring that the fetal diagnostic testing is safe for the fetus is crucial in making informed decisions about the pregnancy. Other choices are less important as safety directly impacts the well-being of the fetus, while the duration, cost, and physical discomfort are secondary considerations in comparison.
The nurse is performing Leopold's maneuvers on a pregnant patient at 36 weeks of gestation and determines the fetal lie is longitudinal, palpates the fetal legs in the top of the uterus, and palpates the fetal head above the symphysis pubis. Which fetal presentation does the nurse document in the EHR?
- A. cephalic
- B. compound
- C. transverse
- D. breech
Correct Answer: D
Rationale: The correct answer is D: breech. At 36 weeks of gestation, if the nurse palpates the fetal head above the symphysis pubis and the fetal legs are at the top of the uterus, it indicates a breech presentation where the baby's buttocks or feet are positioned to be delivered first. In a breech presentation, the fetal head is not engaged in the pelvis and is palpable above the symphysis pubis. The longitudinal lie with the fetal legs on top further supports the breech presentation.
Summary:
A: Cephalic presentation would have the fetal head engaged in the pelvis.
B: Compound presentation involves an additional body part alongside the presenting part.
C: Transverse lie would have the baby positioned horizontally across the uterus.
D: Breech presentation aligns with the given scenario of palpating fetal legs on top and head above the symphysis pubis.
The nurse is caring for a client who is scheduled to have an amniocentesis. Which intervention is most important for the nurse to perform after the procedure?
- A. Evaluate need for Rh0D immunoglobulin
- B. Clean site
- C. Administer pain medication
- D. Perform vital signs
Correct Answer: A
Rationale: The correct answer is A: Evaluate need for Rh0D immunoglobulin. After an amniocentesis, it is crucial to assess if the client is Rh-negative and the fetus is Rh-positive. If this is the case, Rh0D immunoglobulin should be administered to prevent Rh incompatibility issues in future pregnancies. This intervention is critical to prevent hemolytic disease in the newborn.
Cleaning the site (B) is important for infection prevention but not the most critical post-procedure intervention. Administering pain medication (C) can be done based on client's discomfort level but not the top priority. Performing vital signs (D) is important but assessing Rh status and administering Rh0D immunoglobulin take precedence.
A 39-week-gestation client is admitted to the labor and delivery unit for a scheduled cesarean delivery. The nurse should inform the surgeon regarding which of the following admission laboratory findings?
- A. Potassium 4.9 mEq/L.
- B. Sodium 136 mEq/L.
- C. Platelet count 75,000 cells/mm3.
- D. White blood cell count 15,000 cells/mm3.
Correct Answer: C
Rationale: A platelet count of 75,000 cells/mm3 is low and could increase the risk of bleeding during surgery. The surgeon should be informed to take appropriate precautions.
A nurse is following the PDSA cycle for quality improvement. Which action will the nurse take for the letter “A”?
- A. Act
- B. Alter
- C. Assess
- D. Approach
Correct Answer: A
Rationale: There are many models for quality improvement and performance improvement. One model is the PDSA cycle: plan, do, study, and act.