Nokea
Which finding in a laboring mother requires immediate intervention?
- A. Contractions occurring every 5 minutes
- B. Late decelerations on fetal heart monitor
- C. Early decelerations on fetal heart monitor
- D. Elevated maternal temperature during labor
Correct Answer: D
Rationale: The correct answer is D: Elevated maternal temperature during labor. This finding indicates a potential infection, such as chorioamnionitis, which can be harmful to both the mother and the baby if not promptly treated. Immediate intervention is necessary to prevent complications like sepsis.
Contractions every 5 minutes (A) are within the normal range for active labor. Late decelerations (B) can indicate uteroplacental insufficiency and require monitoring but not immediate intervention unless persistent. Early decelerations (C) are usually benign and do not typically require immediate action.
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The nurse enters the person's room for the first time. What can the nurse do to show cultural sensitivity?
- A. Come in and sit on the bed with the person.
- B. Address the person by their first name.
- C. Make and hold eye contact.
- D. Document their preferred language in their chart.
Correct Answer: D
Rationale: The correct answer is D because documenting the person's preferred language in their chart shows cultural sensitivity by ensuring effective communication. This step acknowledges and respects the person's cultural background and language preferences, facilitating better understanding and care provision.
Choices A, B, and C are incorrect:
A: Sitting on the bed may invade personal space and not be culturally appropriate.
B: Addressing the person by their first name may not be respectful in some cultures.
C: Making and holding eye contact may be considered rude or inappropriate in certain cultures.
Which statement by the client would alert the nurse that she should not take oral contraceptives?
- A. I drink one to two alcohol drinks a few times a week.
- B. I am slightly overweight and have a difficult time fitting exercise into my schedule.
- C. I am trying to limit cigarettes to one pack a week.
- D. I try to have my boyfriend wear a condom every time we have sex.
Correct Answer: C
Rationale: The correct answer is C because smoking while taking oral contraceptives increases the risk of blood clots, stroke, and heart attack. Smoking and oral contraceptives together pose a higher risk than either alone. Choices A, B, and D are not direct contraindications for taking oral contraceptives. A: Moderate alcohol consumption is generally not contraindicated. B: Being slightly overweight and having difficulty with exercise are not absolute contraindications. D: Using condoms is a good practice but does not specifically indicate a reason not to take oral contraceptives.
A client in the second stage of labor reports intense rectal pressure. What does this finding indicate?
- A. The baby is in a breech position.
- B. Cervical dilation is incomplete.
- C. The baby is descending into the birth canal.
- D. Labor contractions are ineffective.
Correct Answer: C
Rationale: Step 1: In the second stage of labor, the baby is descending into the birth canal for delivery.
Step 2: Intense rectal pressure is a common sensation as the baby moves down.
Step 3: This indicates progress in labor as the baby is descending.
Step 4: Choice A is incorrect as breech position presents differently.
Step 5: Choice B is incorrect as incomplete cervical dilation may not cause rectal pressure.
Step 6: Choice D is incorrect as effective labor contractions are needed for descent.
A client at 20 weeks' gestation asks about fetal movements. What is the nurse's best response?
- A. Fetal movements are rarely felt before 24 weeks.
- B. You should feel strong, regular movements at this stage.
- C. You may feel fluttering movements, known as quickening.
- D. It is too early to feel any fetal movements.
Correct Answer: C
Rationale: The correct answer is C because quickening, described as fluttering movements, is typically felt by pregnant individuals around 18-20 weeks of gestation. This indicates fetal movement and is an important milestone in pregnancy. Choices A and D are incorrect as fetal movements can be felt as early as 18-20 weeks. Choice B is incorrect as feeling strong, regular movements is not expected until later in the pregnancy.
Nutrition is an integral part of the Bradley Method. What important nutrition advice is taught in this method?
- A. Only eat low-fat foods.
- B. Increase protein to 100 g per day.
- C. Do not eat dairy because it causes food allergies.
- D. Eat a low-protein diet.
Correct Answer: B
Rationale: The correct answer is B because the Bradley Method emphasizes the importance of increasing protein intake to support a healthy pregnancy. Protein is essential for fetal development and maternal health. It is recommended to consume around 100g of protein per day during pregnancy. Adequate protein intake helps in the growth of the baby and helps to maintain the health of the mother.
Explanation of why the other choices are incorrect:
A: Only eat low-fat foods - This is incorrect as fat is also important for a healthy pregnancy and should not be eliminated entirely.
C: Do not eat dairy because it causes food allergies - Dairy is a good source of calcium and other essential nutrients during pregnancy, so this advice is not recommended.
D: Eat a low-protein diet - This is incorrect as protein is crucial for the development of the baby and overall health during pregnancy.