Nokea
The nurse working in an outpatient obstetric office assesses four primigravid clients. Which of the client findings should the nurse highlight for the physician? Select all that apply.
- A. 17 weeks’ gestation; denies feeling fetal movement.
- B. 24 weeks’ gestation; fundal height at the umbilicus.
- C. 27 weeks’ gestation; salivates excessively.
- D. 34 weeks’ gestation; experiences uterine cramping.
Correct Answer: A
Rationale: Denial of fetal movement at 17 weeks and uterine cramping at 34 weeks are concerning findings that should be highlighted for further evaluation. Fundal height at the umbilicus at 24 weeks and excessive salivation at 27 weeks are within normal limits.
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A nurse is assisting a laboring person with a vacuum extraction. What is the most important nursing action to ensure a safe procedure?
- A. monitor fetal heart rate continuously
- B. prepare the person for a cesarean section
- C. monitor for signs of uterine rupture
- D. assist with positioning the person
Correct Answer: B
Rationale: The correct answer is B: prepare the person for a cesarean section. In the scenario of vacuum extraction, if there are complications or the procedure is unsuccessful, the person may need to undergo an emergency cesarean section. By preparing the person for this possibility, the nurse ensures timely intervention if needed, prioritizing the safety of both the person and the baby. Monitoring fetal heart rate continuously (A) is important but not the most crucial action in this case. Monitoring for signs of uterine rupture (C) is not directly related to vacuum extraction. Assisting with positioning (D) is important but not as critical as preparing for a potential cesarean section.
A woman is 36 weeks’ gestation. Which of the following tests will be done during her prenatal visit?
- A. Glucose challenge test.
- B. Amniotic fluid volume assessment.
- C. Vaginal and rectal cultures.
- D. Karyotype analysis.
Correct Answer: C
Rationale: Vaginal and rectal cultures are performed to check for Group B Streptococcus (GBS), which can affect the newborn. Glucose challenge tests are typically done earlier in pregnancy, and karyotype analysis is not routine.
A nurse is teaching a lesson on fetal development to a class of high school students and explains the primary germ layers. What are the germ layers? (Select all that apply.)
- A. Ectoderm
- B. Endoderm
- C. Mesoderm
- D. Plastoderm
Correct Answer: A
Rationale: The zygote transforms its embryonic disc into three layers: the ectoderm, the mesoderm, and the endoderm. These layers are responsible for the development of various tissues and organs in the body. Plastoderm and Blastoderm are not part of the primary germ layers.
A nurse is caring for a postpartum person who is at risk for uterine atony. What is the priority intervention to prevent uterine atony?
- A. administer uterotonic medication
- B. administer an analgesic
- C. perform uterine massage
- D. administer IV fluids
Correct Answer: B
Rationale: The correct answer is B: administer an analgesic. This is the priority intervention because pain management helps the person relax, which reduces stress on the uterus and promotes effective contraction to prevent uterine atony. Administering uterotonic medication (choice A) may help contract the uterus but addressing pain first is crucial. Performing uterine massage (choice C) can assist in contracting the uterus but is not the priority intervention. Administering IV fluids (choice D) is important for hydration but does not directly address preventing uterine atony.
A nurse is caring for a postpartum person who is breastfeeding. What is the most important action to support successful breastfeeding?
- A. educate the person on proper latch
- B. support skin-to-skin contact
- C. promote frequent feeding
- D. educate on postpartum care
Correct Answer: B
Rationale: The correct answer is B: support skin-to-skin contact. Skin-to-skin contact immediately after birth helps regulate the baby's body temperature, promotes bonding, and enhances breastfeeding success by stimulating the baby's natural instincts to latch on and feed. This action establishes a strong foundation for successful breastfeeding.
Rationale:
1. Skin-to-skin contact promotes bonding and attachment between the parent and baby, creating a supportive environment for breastfeeding.
2. It helps regulate the baby's body temperature, ensuring they are comfortable and more willing to breastfeed effectively.
3. Skin-to-skin contact triggers the baby's natural feeding reflexes, making it easier for them to latch on properly.
4. This action fosters a positive breastfeeding experience for both the parent and baby, setting the stage for successful breastfeeding.
Summary:
- Choice A: educating on proper latch is important, but skin-to-skin contact is more crucial for establishing successful breastfeeding.
- Choice C: promoting frequent feeding is beneficial, but skin-to