Nokea
The nurse is educating a client about signs of labor. Which symptom indicates true labor?
- A. Irregular contractions relieved by rest.
- B. Contractions felt only in the abdomen.
- C. Contractions that increase in intensity and cause cervical changes.
- D. Absence of fetal movement.
Correct Answer: C
Rationale: True labor is characterized by contractions that progressively increase in intensity and result in cervical dilation and effacement.
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Teratogens are substances or agents that can cause congenital abnormalities or birth defects in a developing embryo or fetus during pregnancy. What is a true statement about teratogens?
- A. Vitamins can help prevent abnormalities due to teratogens.
- B. Their impact on the fetus depends on factors such as timing and duration of exposure during pregnancy.
- C. They include only medications that a pregnant person may take.
- D. They can be avoided by immunizations.
Correct Answer: B
Rationale:
The nurse is caring for a client in labor receiving epidural anesthesia. What is the priority nursing assessment?
- A. Assess for bladder distention.
- B. Monitor maternal blood pressure.
- C. Evaluate fetal heart rate.
- D. Check for pain relief.
Correct Answer: B
Rationale: Maternal blood pressure monitoring is essential to detect and manage hypotension, a common side effect of epidural anesthesia.
A nurse is teaching a client who is 28 weeks of gestation and not up-to date on current immunization. Which of the following immunizations should the nurse inform the client to anticipate receiving following birth?
- A. Pneumococcal
- B. Hepatitis
- C. Human papillomavirus
- D. Rubella
Correct Answer: D
Rationale: The CDC recommends that women who are not up-to-date with the MMR (measles, mumps, rubella) vaccine should receive it immediately postpartum. Rubella, also known as German measles, is particularly important during pregnancy because contracting rubella during pregnancy can lead to serious complications in the baby, such as birth defects and miscarriage. By ensuring the client receives the MMR vaccine postpartum, it helps protect both the mother and any future pregnancies from the risk of rubella infection.
Which component is important to include in the sexual history assessment to assess the risk of sexually transmitted infections (STIs)?
- A. current sexual activity
- B. reproductive plans
- C. education and counseling
- D. history of HIV testing
Correct Answer: A
Rationale:
A nurse is caring for a client who is gravida 3, para 2, and is in active labor. The fetal head is at 3+ station after a vaginal examination. Which of the following actions should the nurse take
- A. Apply fundal pressure.
- B. Observe for the presence of a nuchal cord.
- C. Observe for crowning.
- D. Prepare to administer oxytocin.
Correct Answer: C
Rationale: Observing for crowning is the appropriate action for the nurse to take when the fetal head is at 3+ station after a vaginal examination. Crowning refers to the appearance of the baby's head at the vaginal opening during delivery. This indicates that the baby is descending and will be born soon. It is important for the nurse to be prepared for the actual birth once crowning is observed, as it signifies that the second stage of labor is progressing and delivery is imminent. Applying fundal pressure, observing for a nuchal cord, or preparing to administer oxytocin are not appropriate actions at this stage of labor when crowning has been observed.