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The nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which is noted on the external monitor tracing during a contraction?
- A. Variability
- B. Accelerations
- C. Early decelerations
- D. Variable decelerations
Correct Answer: D
Rationale: Variable decelerations are a hallmark sign of umbilical cord compression, requiring immediate monitoring and intervention.
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A neonate born at 34 weeks' gestation and weighing 6lbs, 10oz (2750g) is admitted to the nursery, The vital signs are: apical heart rate 130; respiration 58, BP- 60/20. Temp. 98 degrees F; Apgar score of 4 and 8. The nurse should designate the highest priority health outcomes to be:
- A. Oxygenation will remain adequate
- B. Body temperature will remain stable
- C. Weight will increase by 30g per day
- D. Heart rate will recover to an acceptable range
Correct Answer: A
Rationale: Oxygenation is critical for pre-term infants.
Which assessment finding indicates a complication in a client attempting a VBAC?
- A. Complaint of pain between the scapula (could be uterine
- C. Contraction every 3 minutes lasting 70 seconds
- D. Pain level 6 at acme of
Correct Answer: C
Rationale: A client attempting a Vaginal Birth After Cesarean (VBAC) is at higher risk for uterine rupture. A concerning assessment finding in this scenario would be the occurrence of contractions every 3 minutes that are lasting 70 seconds. This pattern of contractions could potentially indicate uterine hyperstimulation, which increases the risk of uterine rupture. It is essential to closely monitor these contractions and address any signs of distress or complications promptly to ensure the safety of both the mother and the baby.
What signs/symptoms should prompt a woman to seek assessment for ovarian cancer?
- A. Vaginal bleeding and weight loss.
- B. Frequent urination, breast tenderness, and extreme fatigue.
- C. Abdominal pain, bloating, and a constant feeling of fullness.
- D. Hardness on one side of the abdomen.
Correct Answer: C
Rationale: Abdominal symptoms are common in ovarian cancer.
During the assessment of a newborn, it is most important for the nurse to report a:
- A. Temperature of 97.7 degrees Fahrenheit
- B. Pale pink, rust-colored stain in the diaper
- C. Heart rate that drops to 120 beats/min
- D. Breathing pattern that is diaphragmatic with sternal retractions
Correct Answer: D
Rationale: Sternal retractions indicate respiratory difficulty.
A pregnant client is diagnosed with anemia. What dietary recommendation should the nurse provide?
- A. Increase intake of dairy products.
- B. Consume more lean red meat.
- C. Drink tea with meals.
- D. Avoid citrus fruits.
Correct Answer: B
Rationale: Lean red meat is rich in iron, which is essential for managing anemia during pregnancy.