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The nurse is performing an assessment of a client who is scheduled for a cesarean delivery at 39 weeks of gestation. Which assessment finding indicates the need to contact the health care provider (HCP)?
- A. Hemoglobin of 11 g/dL (110 mmol/L)
- B. Fetal heart rate of 180 beats/minute
- C. Maternal pulse rate of 85 beats/minute
- D. White blood cell count of 12,000 mm3 (12.0 × 109/L)
Correct Answer: B
Rationale: A fetal heart rate of 180 bpm may indicate fetal distress and warrants immediate HCP notification.
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A client in labor is receiving an epidural for pain relief. What is the nurse's priority assessment immediately after the procedure?
- A. Monitor maternal blood pressure.
- B. Assess fetal heart rate.
- C. Check for bladder distention.
- D. Evaluate the client's pain level.
Correct Answer: A
Rationale: Monitoring maternal blood pressure is essential to detect and manage hypotension, a common side effect of epidurals.
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 the second stage of labor. What finding indicates that birth is imminent?
- A. Cervix is fully dilated.
- B. Contractions every 2 minutes.
- C. Fetal heart rate of 140 beats/minute.
- D. Crowning is observed.
Correct Answer: D
Rationale: Crowning, or the appearance of the fetal head at the vaginal opening, indicates that birth is imminent.
A 30-year-old woman is considering the use of emergency contraception. Which of the following is true about its use?
- A. It is most effective when used within 72 hours after unprotected sex.
- B. It should be used at least 5 days after unprotected sex to be effective.
- C. It prevents implantation of a fertilized egg into the uterine wall.
- D. It requires a prescription from a healthcare provider.
Correct Answer: A
Rationale: Emergency contraception is most effective when taken within 72 hours of unprotected sex. Choice B is incorrect as it is not as effective after 5 days. Choice C is incorrect because emergency contraception works primarily by preventing ovulation, not by preventing implantation. Choice D is incorrect because most emergency contraception methods are available over the counter.
The nurse is educating a client about signs of preterm labor. What symptom should be reported immediately?
- A. Frequent urination.
- B. Low back pain and cramping.
- C. Increased appetite.
- D. Braxton Hicks contractions.
Correct Answer: B
Rationale: Low back pain and cramping can indicate preterm labor and should be reported immediately for further evaluation.