Nokea
The nurse notifies the HCP after feeling a pulsating mass during the vaginal examination of a newly admitted full-term pregnant client. Which HCP order should the nurse question?
- A. Prepare for possible cesarean section.
- B. Place the client in a knee-chest position.
- C. Initiate a low-dose oxytocin IV infusion.
- D. Give terbutaline 0.25 mg subcutaneously.
Correct Answer: C
Rationale: The nurse should question the administration of oxytocin (Pitocin). Oxytocin is used for stimulating contraction of the uterus. Uterine contractions can cause further umbilical cord compression. The pulsating mass indicates umbilical cord prolapse, which is a medical emergency. If vaginal birth is not imminent, a cesarean section is preferred in order to prevent hypoxic acidosis. Placing the client in a knee-chest position relieves pressure on the umbilical cord. Terbutaline (Brethine) is a tocolytic agent used to reduce contractions.
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The 42-year-old client who had a partial hydatidiform molar pregnancy 3 months ago asks the nurse whether she and her husband can try conceiving again. Which response by the nurse is incorrect and warrants follow-up action by the observing nurse manager?
- A. “You will need serial levels of beta human chorionic gonadotropin (BHCG) drawn.”
- B. “You cannot conceive ever again because of your risk of choriocarcinoma.”
- C. “You should not become pregnant yet for 6 to 12 months.”
- D. “Your risk of another hydatidiform molar pregnancy is low.”
Correct Answer: B
Rationale: Women who have had a molar pregnancy can conceive again once their BHCG levels are normal and remain normal for a certain time period, usually 6 to 12 months. This response by the nurse is incorrect and should be followed up by the observing nurse manager. Because of the risk of choriocarcinoma, serial serum BHCG testing is completed after a hydatidiform molar pregnancy. Because the client will undergo serial serum BHCG testing after a hydatidiform molar pregnancy, she should not get pregnant for 6 to 12 months until testing is completed and it is confirmed that she does not have a malignancy. Couples with a past history of molar pregnancy have the same statistical chance of conceiving again and having a normal pregnancy as those without.
The nurse is assessing the client who is 34 weeks’ gestation. Place an X where the nurse should place the Doppler first to assess the FHR when the fetus is thought to be left occiput anterior (LOA).
Correct Answer:
Rationale: FHT are best heard in the lower left quadrant of the client’s abdomen when the fetus is LOA.
The nurse correctly explains that the bleeding is the result of sloughing of which structure?
- A. Endometrium
- B. Myometrium
- C. Epimetrium
- D. None of the above
Correct Answer: A
Rationale: Menstrual bleeding occurs due to the sloughing of the endometrium, the inner lining of the uterus, when pregnancy does not occur.
The 22-year-old client tells the clinic nurse that her last menstrual period was 3 months ago, which began on November 21. She has a positive urine pregnancy test. Using Naegele’s rule, which date should the nurse calculate to be the client’s estimated date of confinement (EDC)?
- A. August 28
- B. January 28
- C. August 15
- D. January 15
Correct Answer: A
Rationale: Naegele’s rule is a common method to determine the EDC. To calculate the EDC, subtract 3 months and add 7 days. This makes the EDC August 28. An EDC of January 28 was calculated by adding 2 months and 7 days. An EDC of August 15 was calculated by subtracting 3 months and 6 days. An EDC of January 15 was calculated by adding 2 months and subtracting 6 days.
Which response by the nurse is most accurate?
- A. Fluorescent treponemal antibody absorption (FTA-ABS) test can detect this defect.
- B. Hepatitis B surface antigen (HBsAg) test can detect this defect.
- C. Maternal serum alpha-fetoprotein (AFP) test can detect this defect.
- D. Venereal Disease Research Laboratory (VDRL) test can detect this defect.
Correct Answer: C
Rationale: The maternal serum alpha-fetoprotein (AFP) test screens for neural tube defects like spina bifida by measuring AFP levels.