Nokea
The nurse uses which tool to measure fundal height?
- A. Tape measure
- B. Doppler device
- C. Ultrasound machine
- D. Blood pressure cuff
Correct Answer: A
Rationale: A tape measure is used to measure fundal height, assessing uterine growth and fetal development.
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The nurse responds that, for clients with uncomplicated pregnancies, it is usually best to plan monthly visits for the first 28 weeks and then more frequent visits following which schedule?
- A. Weekly for the remainder of the pregnancy
- B. Every 2 weeks for the remainder of the pregnancy
- C. Every 2 weeks up to 36 weeks, then weekly for the last month
- D. Weekly up to 36 weeks, then twice weekly for the last month
Correct Answer: C
Rationale: Standard prenatal care involves monthly visits until 28 weeks, biweekly until 36 weeks, and weekly thereafter for uncomplicated pregnancies.
The nurse includes which topic in the prenatal education plan for a first-time mother?
- A. Breastfeeding techniques
- B. Advanced labor pain management
- C. Neonatal surgical procedures
- D. Postpartum weight loss strategies
Correct Answer: A
Rationale: Breastfeeding techniques are essential for a first-time mother to ensure successful feeding and bonding with the newborn.
The client had a D&C for treating an incomplete spontaneous abortion. Which statements should the nurse include when preparing the client for discharge the same day? Select all that apply.
- A. “Return for a blood transfusion if bleeding continues to be dark red.”
- B. “Intravenous antibiotics will be prescribed every 8 hours for two days.”
- C. “I can make a referral to a pregnancy loss support group if you like.”
- D. “You need to use contraceptives to avoid getting pregnant for one year.”
- E. “Someone should remain with you at home for the first 12 to 24 hours.”
Correct Answer: C,E
Rationale: The client who had an incomplete spontaneous abortion may experience grief and loss. The nurse should offer to do a referral to a pregnancy loss support group to provide ongoing support after hospital discharge. A D&C is usually performed on an outpatient basis if there are no complications, and the client can return home a few hours after the procedure. Someone should remain with the client to ensure that she is safe and no complications develop. Dark red blood does not necessarily indicate the need for a blood transfusion; it could be old blood. The client should notify the HCP if experiencing heavy bleeding following the D&C. A D&C for treating incomplete spontaneous abortion does not require the routine administration of IV antibiotics. There is no medical need for the client who had a spontaneous abortion to avoid pregnancy for one year.
The nurse is about to auscultate an FHR on the client in triage. What information should the nurse determine first in order to find the correct placement for auscultation?
- A. Position of the fetus
- B. Position of the placenta
- C. Presence of contractions
- D. Where to apply the ultrasonic gel
Correct Answer: A
Rationale: The nurse should first perform Leopold’s maneuvers to determine the fetal position. This will enable proper placement of the Doppler device over the location of the FHR. The position of the placenta can provide important information. However, if the Doppler device is placed over the placenta, the nurse will hear a swishing sound and not the FHR. The FHR is still assessed regardless of the presence of contractions. The nurse who has difficulty obtaining an FHR because of a contraction can listen again once the contraction has concluded. Ultrasonic gel is used with any ultrasound device and allows for the conduction of sound and continuous contact of the device with the maternal abdomen. In order to apply the gel to the correct location, the position of the fetus must be known.
Which condition increases the risk of congenital anomalies in the fetus?
- A. Maternal diabetes
- B. Mild anemia
- C. Normal weight gain
- D. Regular exercise
Correct Answer: A
Rationale: Maternal diabetes, if poorly controlled, increases the risk of congenital anomalies due to elevated blood glucose levels.