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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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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.
Be- tions before finding one that works.
- A. Once you take the prescribed medication, you plan on teaching this client? will be cured of the infection.
- B. Breastfeeding
- C. Even though you don't experience symptoms,
- D. Postpartum depression you can still spread the infection.
Correct Answer: C
Rationale: Option C is the most appropriate statement to make to the client because it addresses the reality of sexually transmitted infections (STIs). Many STIs can be transmitted even when the infected individual is not experiencing any symptoms. This is an important point to communicate to prevent the spread of the infection to other sexual partners. It emphasizes the need for practicing safe sex measures and getting tested regularly, regardless of the presence of symptoms. It is important for the client to understand that they can still be a carrier of the infection even if they are not displaying any noticeable symptoms.
A client in labor is receiving epidural anesthesia. What is the priority nursing intervention?
- A. Monitor maternal heart rate.
- B. Assess for bladder distention.
- C. Check maternal blood pressure frequently.
- D. Encourage frequent position changes.
Correct Answer: C
Rationale: Frequent monitoring of maternal blood pressure is essential to detect and manage hypotension caused by epidural anesthesia.
The patient came for an induction and under which circumstances does the nurse remove prostaglandin from the patient's cervix? SATA
- A. N&V
- B. Late deceleration
- C. Contractions every 90 seconds
- D. Contractions every 5 minutes
Correct Answer: B
Rationale: A. Nausea and vomiting (N&V) are not typically indications for removing prostaglandin from the patient's cervix during induction. These symptoms are common side effects and can be managed without removing the prostaglandin.
The nurse assesses a patient for medical eligibility for contraceptive use. What is the meaning of an MEC score of 2?
- A. There is no restriction for the use of the contraceptive method.
- B. There is an unacceptable health risk if the contraceptive method is used.
- C. There is a risk that outweighs the advantages of the contraceptive method.
- D. There is an advantage of using a contraceptive method that outweighs any risk.
Correct Answer: B
Rationale: An MEC score of 2 indicates that there is an unacceptable health risk if the contraceptive method is used. This means that the potential health risks associated with using this particular contraceptive method outweigh the benefits. Therefore, the nurse should advise against using this method for contraception due to the elevated health risks involved. It is essential for healthcare providers to meticulously assess the medical eligibility of a patient before recommending any contraceptive method to ensure the safety and well-being of the individual.