Nokea
The nurse is caring for a pregnant patient who is 37 weeks gestation and is experiencing contractions every 10 minutes. Which of the following should the nurse assess first?
- A. The patient's vital signs and fetal heart rate
- B. The patient's cervical dilation and effacement
- C. The patient's urinary output and fluid balance
- D. The patient's emotional status and support system
Correct Answer: B
Rationale: The correct answer is B: The patient's cervical dilation and effacement. At 37 weeks gestation with contractions every 10 minutes, assessing cervical dilation and effacement is crucial to determine if the patient is in active labor. This information will guide the nurse in determining the appropriate next steps for the patient's care, such as the need for further monitoring or interventions. Assessing vital signs and fetal heart rate (Choice A) is important but not the priority in this scenario. Urinary output and fluid balance (Choice C) are important considerations but not the immediate priority. Emotional status and support system (Choice D) are also important but not the first assessment to be made in this situation.
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The nurse who will care for a patient in labor receives a report and is told that the patient's status is as follows: 4 cm, 50%, and +1 station. What should be the nurse's interpretation of this information?
- A. The cervix is effaced 4 cm, is dilated to 50%, and is 1 cm below the ischial spines.
- B. The cervix is dilated 4 cm, is effaced to 50%, and is 1 cm above the ischial spines.
- C. The cervix is dilated 4 cm, is effaced to 50%, and is 1 cm below the ischial spines.
- D. The cervix is effaced 4 cm, is dilated to 50%, and is 1 cm above the ischial spines.
Correct Answer: C
Rationale: The correct interpretation is C because in labor progress, cervical dilation (4 cm) refers to how much the cervix has opened, effacement (50%) indicates the thinning of the cervix, and station (+1) describes the descent of the baby's head in relation to the ischial spines. Therefore, the nurse should understand that the cervix is dilated 4 cm, effaced 50%, and the baby's head is 1 cm below the ischial spines, which is indicative of progressing labor.
Choice A is incorrect because it incorrectly describes the station as being 1 cm below the ischial spines instead of above. Choice B is incorrect as it inaccurately states that the cervix is effaced to 50% rather than dilated. Choice D is incorrect because it states that the cervix is effaced 4 cm, which is not a correct representation of effacement.
A gravid woman who recently emigrated from mainland China is being seen at her first prenatal visit. She was never vaccinated in her home country. An injection to prevent which of the following communicable diseases should be administered to the woman during her pregnancy?
- A. Influenza.
- B. Mumps.
- C. Rubella.
- D. Varicella.
Correct Answer: A
Rationale: Influenza vaccination is safe and recommended during pregnancy to protect both the mother and fetus. Vaccines for Mumps, Rubella, and Varicella are live attenuated vaccines and are contraindicated during pregnancy.
The nurse is caring for a pregnant patient who is 38 weeks gestation and has a history of gestational hypertension. Which of the following symptoms would indicate the need for immediate medical attention?
- A. Mild swelling in the feet and ankles
- B. Headaches and blurred vision
- C. Occasional lower back pain
- D. Fatigue and slight nausea
Correct Answer: B
Rationale: The correct answer is B: Headaches and blurred vision. These symptoms can indicate a serious condition called preeclampsia, which can be life-threatening for both the mother and the baby. Headaches and blurred vision are signs of increased blood pressure and potential organ damage. Immediate medical attention is crucial to monitor and manage preeclampsia.
A: Mild swelling in the feet and ankles is common in pregnancy and not necessarily indicative of a serious issue.
C: Occasional lower back pain is also common in pregnancy and may not require immediate medical attention.
D: Fatigue and slight nausea are common pregnancy symptoms and do not typically indicate a need for immediate medical attention.
What complication can result from untreated respiratory distress in the newborn?
- A. Esophageal atresia
- B. Gastric dilation
- C. Cold stress
- D. Reopening of the foramen ovale
Correct Answer: D
Rationale: Respiratory distress can cause increased pressure in the right ventricle, causing reopening of the foramen ovale.
The nurse is caring for a woman who is pregnant and reports that she has used tobacco throughout her pregnancy. What is the most likely risk to her baby?
- A. Neonatal death
- B. Fetal alcohol syndrome
- C. Low birth weight
- D. Cerebral palsy
Correct Answer: C
Rationale: The correct answer is C: Low birth weight. Tobacco use during pregnancy is associated with several adverse outcomes, including low birth weight. Nicotine in tobacco can constrict blood vessels, reducing the flow of oxygen and nutrients to the baby, leading to poor growth and low birth weight. Neonatal death (A) is a severe outcome but not the most likely risk associated with tobacco use during pregnancy. Fetal alcohol syndrome (B) is caused by alcohol consumption, not tobacco use. Cerebral palsy (D) is a neurological condition not directly linked to tobacco use during pregnancy.