Nokea
The nurse is monitoring a client in active labor with ruptured membranes. What finding requires immediate action?
- A. Contractions every 3–5 minutes.
- B. Temperature of 100.4°F.
- C. Fetal heart rate of 100 beats/minute.
- D. Clear amniotic fluid.
Correct Answer: C
Rationale: The correct answer is C: Fetal heart rate of 100 beats/minute. A fetal heart rate of 100 beats/minute is bradycardia, indicating fetal distress and requiring immediate action to prevent adverse outcomes. Contractions every 3-5 minutes are normal in active labor. A temperature of 100.4°F indicates a low-grade fever but is not an immediate concern unless it continues to rise. Clear amniotic fluid is a normal finding after membrane rupture and does not require immediate action. Therefore, monitoring and addressing the fetal heart rate abnormalities are crucial in this situation.
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A client with a history of hypertension is at 28 weeks' gestation. What complication is she at greatest risk for?
- A. Placenta previa.
- B. Gestational diabetes.
- C. Abruptio placentae.
- D. Preterm labor.
Correct Answer: C
Rationale: The correct answer is C: Abruptio placentae. At 28 weeks, the client with hypertension is at greater risk for abruptio placentae due to increased vascular resistance, leading to potential placental detachment. Placenta previa (A) is more common in the third trimester. Gestational diabetes (B) is more common in later pregnancy and not directly related to hypertension. Preterm labor (D) can be a risk with chronic hypertension but is not the greatest risk at 28 weeks.
The nurse assures the breastfeeding mother that she will know that her infant is getting an adequate supply of breast milk if the infant gains weight and:
- A. Rarely sucks on a pacifier.
- B. Ha several hard stools daily
- C. Voids 6 or more times a day
- D. Awakens to feed every 4 hours
Correct Answer: C
Rationale: The correct answer is C: Voids 6 or more times a day. Adequate breast milk intake is indicated by frequent urination (6 or more times/day) in infants. This shows the infant is hydrated and receiving enough milk. The other choices are incorrect because A) pacifier use doesn't indicate milk supply, B) hard stools can be a sign of dehydration or other issues, and D) feeding every 4 hours is a general guideline but not a definitive indicator of milk supply.
In what stage does the corpus luteum form?
- A. Luteal phase
- B. Follicular phase
- C. Proliferative phase
- D. Shedding of endometrium phase
Correct Answer: A
Rationale: The corpus luteum forms during the luteal phase of the menstrual cycle. After ovulation, the ruptured follicle transforms into the corpus luteum, which secretes progesterone to prepare the uterus for potential pregnancy. If fertilization doesn't occur, the corpus luteum degenerates, leading to a drop in progesterone levels and the start of menstruation. The other choices, such as the follicular phase (B) where the follicles develop, proliferative phase (C) where the endometrium thickens, and shedding of endometrium phase (D) where menstruation occurs, do not involve the formation of the corpus luteum.
The nurse is assessing a client in active labor with variable decelerations on the fetal monitor. What is the priority intervention?
- A. Increase oxytocin infusion.
- B. Reposition the client.
- C. Administer oxygen at 10 L/min.
- D. Perform a vaginal examination.
Correct Answer: B
Rationale: The correct answer is B: Reposition the client. Variable decelerations can indicate umbilical cord compression. Repositioning the client can help relieve the compression, improving fetal oxygenation. Increasing oxytocin (A) could worsen the situation. Administering oxygen (C) may be needed but repositioning is the priority. Performing a vaginal examination (D) is not indicated for variable decelerations.
A patient has delivered twins. The first twin was stillborn, and the second is in the intensive care nursery, recovering quickly from respiratory distress. The patient is crying softly and says, "wish my baby could have lived." What is the most therapeutic response?
- A. "How soon do you plan to have another baby?"
- B. "Don't be sad. At least you have one healthy baby."
- C. "have a friend who lost a twin and she's doing just fine now."
- D. "am so sorry about your loss. Would you like to talk about it?"
Correct Answer: D
Rationale: The correct answer is D because it shows empathy, acknowledges the patient's loss, and invites further discussion if the patient wishes to talk. It validates the patient's feelings and offers support. Choice A is inappropriate as it disregards the patient's current emotional state. Choice B diminishes the patient's grief and may come off as insensitive. Choice C redirects the focus to someone else's experience, which may not be helpful in addressing the patient's emotions.