Nokea
The nurse who has just performed a vaginal examination notes that the fetus is in the LOP position. Which of the following clinical assessments would the nurse expect to note at this time?
- A. Complaints of severe back pain.
- B. Rapid descent and effacement.
- C. Irregular and hypotonic contractions.
- D. Rectal pressure with bloody show.
Correct Answer: A
Rationale: The LOP (left occiput posterior) position often causes back pain due to the fetal head pressing against the mother’s sacrum.
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Which of the following features would the nurse expect to be absent in an 8-week-gestation embryo?
- A. Four-chambered heart.
- B. Fingers and toes.
- C. Fully formed genitalia.
- D. Facial features.
Correct Answer: C
Rationale: At 8 weeks, the embryo’s genitalia are not fully formed, though other features like the heart and facial structures are developing.
A woman is seeking counseling regarding tubal ligation. Which of the following should the nurse include in her discussion?
- A. The woman will no longer menstruate.
- B. The surgery should be done when the woman is ovulating.
- C. The surgery is easily reversible.
- D. The woman will be under anesthesia during the procedure.
Correct Answer: D
Rationale: Tubal ligation is a permanent form of contraception and requires anesthesia. It does not affect menstruation, and reversal is not guaranteed.
A nurse is completing a minimum data set. Which area is the nurse working?
- A. Nursing center
- B. Psychiatric facility
- C. Rehabilitation center
- D. Adult day care center
Correct Answer: A
Rationale: Nurses who work in a nursing center (nursing home or nursing facility) are required to complete a minimum data set on each patient. Minimum data set is not needed for psychiatric, rehabilitation, or adult day care centers.
It is noted that a baby admitted to the nursery has translucent skin with visible veins. Because of this finding, the nurse should monitor this baby carefully for which of the following?
- A. Polycythemia.
- B. Hypothermia.
- C. Hyperglycemia.
- D. Polyuria.
Correct Answer: B
Rationale: Translucent skin with visible veins is common in preterm infants, who are at higher risk for hypothermia due to poor thermoregulation.
A gravida 1 patient at 32 weeks of gestation reports that she has severe lower back pain. What should the nurse's assessment include?
- A. Palpation of the lumbar spine
- B. Exercise pattern and duration
- C. Observation of posture and body mechanics
- D. Ability to sleep for at least 6 hours uninterrupted
Correct Answer: C
Rationale: The correct answer is C. Observation of posture and body mechanics is essential in assessing lower back pain in a pregnant patient to identify any potential causes related to the growing uterus and changes in body mechanics. Palpation of the lumbar spine (Choice A) may provide some information but does not address the underlying issue. Exercise pattern and duration (Choice B) are important but not the priority in this scenario. Ability to sleep for at least 6 hours uninterrupted (Choice D) is not directly related to assessing lower back pain.