Nokea
A nurse is providing prenatal education to a patient who is 8 weeks pregnant. The nurse informs the patient that the developing fetus is most vulnerable to teratogens during what trimester of pregnancy?
- A. first
- B. second
- C. third
- D. fourth
Correct Answer: A
Rationale: The correct answer is A (first trimester). During the first trimester (weeks 1-12), the developing fetus is most vulnerable to teratogens as major organs are forming. Exposure to teratogens during this critical period can lead to severe birth defects. In contrast, the second trimester (weeks 13-26) is a period of rapid growth and development, but most major organs have already formed. The third trimester (weeks 27-birth) focuses on further growth and maturation, with reduced risk of teratogen-related birth defects. The fourth trimester is not a valid option as pregnancy only consists of three trimesters.
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A pregnant patient's biophysical profile score is 8. The patient asks the nurse to explain the results. What is the nurse's most appropriate response?
- A. The test results are within normal limits.'
- B. Immediate birth by cesarean birth is being considered.'
- C. Further testing will be performed to determine the meaning of this score.'
- D. An obstetric specialist will evaluate the results of this profile and, within the next week, will inform you of your options regarding birth.'
Correct Answer: A
Rationale: The correct answer is A: "The test results are within normal limits." A biophysical profile score of 8 is considered normal. A score of 8 out of 10 indicates that the fetus is likely healthy and does not require immediate delivery. The other choices are incorrect because immediate birth by cesarean section is not warranted for a score of 8, further testing is not necessary as the score is normal, and there is no need for an obstetric specialist to evaluate the results urgently. The most appropriate response reassures the patient that the results are normal, providing comfort and clarity.
A client with diabetes mellitus is at 37 weeks gestation. She has had weekly NSTs for the last 3 weeks, and the results have been reactive. This week, the NST was nonreactive after 40 minutes. The nurse anticipates which of the following will be performed for the client based on these results?
- A. Scheduled for an immediate ultrasound
- B. Scheduled for a biophysical profile
- C. Admitted to the hospital for induction of labor
- D. Scheduled for a follow-up appointment for NST in 2 days
Correct Answer: B
Rationale: The correct answer is B: Scheduled for a biophysical profile. At 37 weeks gestation, a nonreactive NST after 40 minutes indicates a need for further evaluation with a biophysical profile to assess fetal well-being comprehensively. This test includes NST along with ultrasound evaluation of amniotic fluid volume, fetal tone, fetal breathing movements, and gross body movements. Biophysical profile provides a more detailed assessment of fetal status compared to NST alone.
Choice A is incorrect because an immediate ultrasound is not the next step after a nonreactive NST. Choice C is incorrect because hospital admission for labor induction is premature based on one nonreactive NST result. Choice D is incorrect because waiting for 2 days for a follow-up NST is not recommended due to the urgency of assessing fetal well-being promptly.
A fetus, descending through the birth canal, is going through the cardinal moves of labor. Please place the following moves in chronological order.
- A. External rotation.
- B. Flexion.
- C. Extension.
- D. Internal rotation.
Correct Answer: D
Rationale: The cardinal movements of labor occur in the following order: flexion, internal rotation, extension, external rotation, and expulsion.
A woman is admitted to the labor and delivery unit with active tuberculosis. She has not been under a physician's care and is not on medication. Which of the following actions should the nursery nurse perform when the neonate is delivered?
- A. Isolate the baby from the other babies in a special care nursery.
- B. Keep the baby in the regular care nursery but separated from the mother.
- C. Isolate the baby with the mother in the mother's room.
- D. Obtain an order from the doctor for antituberculosis medications for the baby.
Correct Answer: A
Rationale: The baby should be isolated to prevent the spread of tuberculosis to other neonates. The mother should also be treated, but the immediate concern is preventing transmission to others.
A postpartum client, who delivered her baby vaginally 2 hours earlier, just voided 100 mL in the bathroom. After returning to bed, the nurse makes the following assessment: fundus 4 cm above the umbilicus and deviated to the right with moderate lochia rubra. Which of the following nursing diagnoses is appropriate at this time?
- A. Impaired skin integrity.
- B. Fluid volume deficit.
- C. Impaired urinary elimination.
- D. Toileting self-care deficit.
Correct Answer: C
Rationale: A deviated fundus and moderate lochia rubra suggest urinary retention, which can impede uterine involution.