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The nurse is monitoring a client who is 34 weeks ges- dividing?
- A. Trophoblast or inner cell mass that becomes the fetal monitor tracing are a priority for the nurse to placenta
- B. Embryoblast or inner cell mass that becomes the that apply. embryo
- C. Baseline FHR 140, accelerations, late decelerations,
- D. Morula
Correct Answer: A
Rationale: In the context of the question, the nurse is monitoring a 34-week gestation client. At 34 weeks, the trophoblast or inner cell mass has already developed into the placenta, which is formed earlier in pregnancy. Therefore, choice A is the most relevant option in this scenario. Trophoblast is critical for implantation and the formation of the placenta, which plays a vital role in supporting the developing fetus by providing oxygen and nutrients. Understanding the different stages of fetal development can help the nurse provide optimal care and monitor for any potential issues that may arise during pregnancy.
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A patient who was diagnosed prenatally as having epidural for pain management. What should the greater than 2,000 mL of amniotic fluid just deliv- nurse be prepared to do? Select all that apply. ered a 9 lb (4,082 g) baby girl. Her nurse is aware
- A. Assess maternal vital signs that she is now at risk for which condition?
- B. Assess FHR
- C. Infection
- D. Assist patient to the bathroom to void
Correct Answer: A
Rationale: A. Assess maternal vital signs: With the delivery of a baby with macrosomia (greater than 4,000 g), the mother is at risk for postpartum hemorrhage due to uterine atony, retained placental fragments, or lacerations. Therefore, assessing maternal vital signs is crucial in detecting any signs of hemorrhage promptly.
What teaching is most important for a mother with a newborn receiving phototherapy?
- A. Ensure the newborn wears protective eyewear
- B. Increase the newborn's fluid intake
- C. Turn the newborn frequently to prevent pressure sores
- D. Monitor bilirubin levels every 8 hours
Correct Answer: A
Rationale: Protective eyewear prevents retinal damage during phototherapy.
The nurse discusses treatment for side effects of perimenopause. What education should be provided?
- A. Menopausal hormone therapy can decrease symptoms of menopause.
- B. Hot flashes are normal, and no one should need treatment for this symptom.
- C. Medications to decrease estrogen can help with insomnia.
- D. Depression is normal, so no treatment is needed.
Correct Answer: A
Rationale:
A client at 36 weeks' gestation reports decreased fetal movement. What is the nurse's priority action?
- A. Perform a nonstress test.
- B. Encourage the client to drink orange juice.
- C. Schedule an ultrasound.
- D. Notify the healthcare provider.
Correct Answer: A
Rationale: A nonstress test evaluates fetal well-being and is the first step in assessing decreased fetal movement.
Which action by the nurse prevents infection in the labor and birth area?
- A. Keeping under pad and linen as dry as possible
- B. Performing vaginal exam q hour while client in active area
- C. Cleaning secretion from vaginal area using back to front
- D. Using clean technique for all procedures
Correct Answer: D
Rationale: Using clean technique for all procedures helps prevent infection in the labor and birth area. A clean technique involves maintaining cleanliness and limiting contamination during procedures. This includes proper hand hygiene, use of clean gloves, and ensuring that equipment and supplies are kept clean and sterile as needed. By adhering to clean techniques, the nurse reduces the risk of introducing harmful microorganisms into the labor and birth area, ultimately reducing the chances of infection for both the mother and baby. It is important for the nurse to practice proper infection control measures to provide a safe environment for labor and birth.