Nokea
The nurse is caring for a client in the second stage of labor. What finding indicates readiness for delivery?
- A. Fetal head is at station 0.
- B. Contractions every 3–5 minutes.
- C. Fetal head is crowning.
- D. Cervix is dilated to 8 cm.
Correct Answer: C
Rationale: Crowning indicates that the fetal head is visible at the vaginal opening, signifying readiness for delivery.
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What is the recommended position for a laboring mother with variable decelerations?
- A. Position the mother in a supine position
- B. Encourage the mother to change positions frequently
- C. Advise using a peanut ball to widen the pelvis
- D. Position the mother in a side-lying position
Correct Answer: D
Rationale: Side-lying reduces pressure on the umbilical cord, improving fetal oxygenation.
A patient who has an LNG-IUC in place calls the office and states she just took a pregnancy test, and it is positive. She comes in for a visit, and the nurse does another pregnancy test, which is positive. What does the nurse know that the clinician will inform the patient regarding the IUC?
- A. Removing the IUC may increase the chance of infertility.
- B. The fetus is at risk for congenital defects.
- C. The IUC needs to be removed regardless of the plans for this pregnancy.
- D. There is no risk to the fetus if the IUC is left in place.
Correct Answer: D
Rationale: The correct statement the nurse knows that the clinician will inform the patient regarding the LNG-IUC is that there is no risk to the fetus if the IUC is left in place. The LNG-IUC (levonorgestrel-releasing intrauterine system) is a highly effective form of contraception that works by releasing progesterone locally in the uterus. The hormonal effect of the LNG-IUC is mostly limited to the uterus and very little of it circulates systemically. Therefore, there is no known increased risk of congenital defects or harm to the fetus if the IUC is left in place during pregnancy. The IUC can be left in place if the patient chooses to continue the pregnancy, provided there are no signs of infection or other complications that would necessitate its removal.
What education should a nurse provide for safe sleeping practices for a newborn?
- A. Place the newborn in the prone position
- B. Use a firm mattress and avoid loose bedding
- C. Use a soft mattress and co-sleep with the baby
- D. Encourage side-lying sleeping position
Correct Answer: B
Rationale: Using a firm mattress and avoiding loose bedding reduces the risk of SIDS.
The nurse is performing an assessment of a postpartum client. Which finding requires immediate action?
- A. Temperature of 100.4°F.
- B. Foul-smelling lochia.
- C. Fundus firm and midline.
- D. Breast tenderness on palpation.
Correct Answer: B
Rationale: Foul-smelling lochia may indicate an infection and requires prompt medical evaluation.
Which newborn is at higher risk for developing hypoglycemia? SATA
- A. SGA
- B. Post term newborn
- C. LGA
- D. 38 week gestation (term newborn)
Correct Answer: A
Rationale: - Small for gestational age (SGA) newborns are at higher risk for developing hypoglycemia due to limited glycogen stores and decreased adipose tissue for energy reserve.