Nokea
The nurse is caring for the client admitted to the antepartum unit at 32 weeks’ gestation with possible preterm labor. The nurse is performing a fetal fibronectin (fFN) test. Which event, if it occurred, would require the nurse to recollect the specimen?
- A. The specimen is collected before a vaginal examination.
- B. A lubricant was used to facilitate insertion of the swab.
- C. The client reports that she has not had intercourse for 3 days.
- D. The specimen is collected before other specimens are collected.
Correct Answer: B
Rationale: When collecting a fetal fibronectin test swab, the nurse must not use lubricant, as it will interfere with the collection of the specimen and contaminate the specimen. If this occurs, the test will need to be repeated. The specimen needs to be collected before a vaginal examination in order to ensure that the fluids are not contaminated. The client must not have had sexual intercourse within 24 hours of the specimen collection, as semen will contaminate the specimen. The specimen must be collected before other specimens are collected to maintain the integrity of the specimen.
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The nurse advises the client to clean the newborn's umbilical cord with which substance?
- A. Alcohol or antiseptic as prescribed
- B. Soap and water
- C. Hydrogen peroxide
- D. No cleaning needed
Correct Answer: A
Rationale: Cleaning with alcohol or antiseptic as prescribed prevents infection until the cord stump falls off.
The nurse recognizes which behavior as a sign of potential depression in a pregnant client?
- A. Occasional fatigue
- B. Persistent sadness and withdrawal
- C. Increased appetite
- D. Excitement about the pregnancy
Correct Answer: B
Rationale: Persistent sadness and withdrawal are hallmark signs of depression, requiring further assessment and intervention.
The nurse correctly explains to the group that the discomfort associated with varicose veins is relieved by which activity?
- A. Resting with the feet in a dependent position
- B. Sitting for periods of time when possible
- C. Putting on calf-length, elastic-top hose
- D. Moving around after standing in one position
Correct Answer: C
Rationale: Elastic-top hose improves venous return, reducing discomfort from varicose veins, unlike dependent positioning or sitting.
The nurse identifies which factor as increasing the risk of gestational hypertension?
- A. Low body mass index
- B. Family history of hypertension
- C. First pregnancy at age 20
- D. Vegetarian diet
Correct Answer: B
Rationale: A family history of hypertension increases the risk of gestational hypertension, as genetics play a significant role.
The oncoming shift nurse assesses the fundus of the postpartum client 6 hours after a vaginal birth and finds that it is firm. When the nurse then assists the client out of bed for the first time, blood begins to run down the client’s leg. Which action by the nurse in response to the client’s bleeding is correct?
- A. Explain that extra bleeding can occur with initial standing
- B. Immediately assist the client back into bed
- C. Push the emergency call light in the room
- D. Call the HCP to report this increased bleeding
Correct Answer: A
Rationale: Lochia normally pools in the vagina when the postpartum client remains in a recumbent position for any length of time. When the client then stands, gravity causes the blood to flow out. As long as the nurse knows the fundus is firm and not bleeding, a simple explanation to the client is all that is required. There is no reason to return the client to bed; the fundus is firm. There is no reason to push the emergency call light. Increased bleeding is an expected response when standing for the first time. There is no reason to call the HCP.