Nokea
The physician has determined the need for forceps. The nurse should explain to the patient that the need for forceps is indicated because
- A. Premature placental separation (also used for prolapsed cord and nonreasoning fetal HR)
- B. Her support person is exhausted
- C. To shorten the first stage of labor
- D. To prevent fetal distress
Correct Answer: A
Rationale: Forceps delivery is indicated in situations where there is fetal distress due to premature placental separation or nonreassuring fetal heart rate. Forceps are used to facilitate a quicker delivery and reduce the risk to the baby during such emergency situations. Forces are also used in cases of fetal distress due to a prolapsed cord where a quick delivery is necessary to relieve pressure on the umbilical cord.
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A client at 35 weeks' gestation reports mild vaginal bleeding and no pain. What condition should the nurse suspect?
- A. Abruptio placentae.
- B. Placenta previa.
- C. Preterm labor.
- D. Urinary tract infection.
Correct Answer: B
Rationale: Painless vaginal bleeding in late pregnancy is a classic sign of placenta previa.
When reviewing the arterial blood gas values for a client, a nurse notes a pH of 7.32, PaCO2 of 48 mm Hg, and HCO3 of 23 mEq/L. What does this indicate about the acid-base balance?
- A. Respiratory acidosis
- B. Respiratory alkalosis
- C. Metabolic acidosis
- D. Metabolic alkalosis
Correct Answer: A
Rationale: The given values suggest respiratory acidosis. In respiratory acidosis, the pH is low (<7.35), PaCO2 is high (>45 mm Hg), and the HCO3 is normal or slightly elevated. In this scenario, the low pH (7.32) and high PaCO2 (48 mm Hg) indicate respiratory acidosis, where there is an excess of carbon dioxide in the blood, leading to acidification of the body fluids.
The nurse is assessing a pregnant client with hyperemesis gravidarum. What is the priority nursing action?
- A. Monitor for dehydration and electrolyte imbalances.
- B. Encourage the client to eat small, frequent meals.
- C. Provide antiemetic medication as prescribed.
- D. Assess for fetal growth restriction.
Correct Answer: A
Rationale: Monitoring for dehydration and electrolyte imbalances is critical due to the risk of complications from persistent vomiting.
The nurse is educating a patient on what constitutes IPV. What is an example of an act of IPV?
- A. child endangerment
- B. stalking
- C. workplace harassment
- D. legal allegations
Correct Answer: B
Rationale: Stalking is a deliberate act where the perpetrator repeatedly follows, harasses, or intimidates the victim, which can instill fear or threaten safety. It is recognized as a specific form of intimate partner violence (IPV).
Which newborn reflex is assessed by stroking the cheek?
- A. Startle reflex
- B. Rooting reflex
- C. Babinski reflex
- D. Sucking reflex
Correct Answer: B
Rationale: The rooting reflex is observed when stroking the cheek, helping the newborn find the breast for feeding.