Nokea
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 finding in a 36-week pregnant client is most concerning?
- A. Braxton Hicks contractions
- B. Frequent urination
- C. Proteinuria of +2
- D. Weight gain of 2 pounds in a week
Correct Answer: C
Rationale: Proteinuria is a sign of preeclampsia, requiring immediate assessment.
An African American woman noticed bruises on a newborn girl's buttocks, and she asks the nurse who spanked the baby? The nurse responds
- A. Mongolian spots
- B. Ecchymosis
- C. Birth trauma
- D. Petechiae
Correct Answer: A
Rationale: Mongolian spots are a common benign skin condition in newborn babies, especially those with darker skin tones, such as African American babies. These spots appear as blue or purple bruises or patches, typically on the lower back and buttocks, and can easily be mistaken for bruises caused by physical harm. It is important for healthcare providers and caregivers to be aware of Mongolian spots to avoid confusion with signs of abuse. In this case, the nurse is likely explaining that the bruises on the newborn girl's buttocks are due to Mongolian spots, not being spanked.
A nurse is caring for a client who is 4hr postpartum and is experiencing hypovolemic shock. Which of the following actions should the nurse take?
- A. Administer indomethacin
- B. Insert a second using a 22-gauge IV catheter.
- C. Insert an indwelling urinary catheter.
- D. Administer oxygen at 4L/min via nasal cannula.
Correct Answer: B
Rationale: The priority action for a client experiencing hypovolemic shock is to restore circulating volume. Inserting a second IV using a 22-gauge catheter would allow for rapid administration of IV fluids to help restore blood volume and improve circulation. This intervention is crucial in managing hypovolemic shock to prevent further complications and stabilize the client's condition. Administering indomethacin, inserting an indwelling urinary catheter, or administering oxygen, while potentially necessary in some cases, are not the immediate priority in managing hypovolemic shock.
As a nurse working in a prenatal clinic. It is important to obtain maternal and fetal assessing. While obtaining fetal assessments. Which of the following should the complete for fetal well-being?
- A. Fetal movement, maternal vital signs, maternal weight
- B. Fetal movement, fetal position, fetal weight
- C. Fetal position, fetal heart tone, maternal weight
- D. Fetal heart tones, fetal movement, fundal height
Correct Answer: D
Rationale: When assessing fetal well-being in a prenatal clinic, it is important to focus on factors directly related to the fetus. Fetal heart tones provide crucial information about the baby's heart rate and rhythm, indicating how well the fetus is doing. Fetal movement is another essential indicator of fetal well-being, as it shows signs of good neurological function and reactivity. Finally, measuring fundal height (the distance from the top of the uterus to the pubic bone) helps assess fetal growth and development. These three aspects - fetal heart tones, fetal movement, and fundal height - provide a comprehensive evaluation of the baby's well-being and development during pregnancy.
A laboring patient's obstetrician suggested an amniotomy as a method for inducing the labor. Which assessment must be made before the amniotomy is performed?
- A. Fetal presentation, position, and station
- B. Estimate fetal birth weight
- C. Maternal temperature, BP, pulse
- D. Biparietal diameter
Correct Answer: A
Rationale: Before performing an amniotomy (artificial rupture of membranes), it is essential to assess the fetal presentation, position, and station. This assessment helps ensure that the procedure is performed safely without causing harm to the baby. Knowing the fetal presentation (such as breech, transverse, or vertex), position (occiput anterior, occiput posterior, etc.), and station (how far down the baby's head is in the pelvis) allows the obstetrician to determine the best approach and technique for the amniotomy. It also helps in reducing the risk of complications during labor induction and delivery. Therefore, this assessment is crucial in ensuring the well-being of both the mother and the baby during the labor process.