Nokea
The nurse is caring for a client in the second stage of labor. What finding indicates readiness for delivery?
- A. Fetal head is at station 0.
- B. Contractions every 3–5 minutes.
- C. Fetal head is crowning.
- D. Cervix is dilated to 8 cm.
Correct Answer: C
Rationale: Crowning indicates that the fetal head is visible at the vaginal opening, signifying readiness for delivery.
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Which of the following medications should the nurse plan to administer?
- A. Metronidazole
- B. Penicillin
- C. Acyclovir
- D. Gentamicin
Correct Answer: A
Rationale: Among the medications listed, Metronidazole is commonly used to treat anaerobic bacterial infections, protozoal infections, and certain types of parasitic infections. It is effective against a wide range of pathogens, making it a versatile antibiotic. In this case, the nurse should plan to administer Metronidazole based on the information given in the question. Penicillin is primarily used for Gram-positive bacterial infections, Acyclovir is used for herpes virus infections, and Gentamicin is an aminoglycoside antibiotic typically used for Gram-negative bacterial infections.
What is the second stage of pathophysiology in an on anticoagulant therapy due to a deep vein throm- amniotic fluid embolism characterized by? bosis, which occurred after giving birth. Which of
- A. Hemorrhage the following instructions should the nurse include?
- B. Hypoxia
- C. Take an herbal supplement such as St. John's wort
- D. Capillary damage to help increase the effect of the anticoagulant.
Correct Answer: A
Rationale: The second stage of pathophysiology in an amniotic fluid embolism characterized by deep vein thrombosis on anticoagulant therapy after giving birth involves the risk of hemorrhage. Anticoagulant therapies such as heparin increase the risk of bleeding since they inhibit the blood's ability to clot effectively. This means that in the event of an injury or surgery, there is a higher likelihood of excessive bleeding. Therefore, it is crucial to monitor for signs of hemorrhage such as bruising, bleeding gums, blood in urine or stool, and low blood pressure. Intervention to manage bleeding may include reducing the dosage of the anticoagulant, administering blood products, and implementing pressure or surgical interventions as necessary.
The nurse is educating a client about signs of labor. Which symptom indicates true labor?
- A. Irregular contractions relieved by rest.
- B. Contractions felt only in the abdomen.
- C. Contractions that increase in intensity and cause cervical changes.
- D. Absence of fetal movement.
Correct Answer: C
Rationale: True labor is characterized by contractions that progressively increase in intensity and result in cervical dilation and effacement.
The nurse is caring for a client in labor receiving epidural anesthesia. What is the priority nursing assessment?
- A. Assess for bladder distention.
- B. Monitor maternal blood pressure.
- C. Evaluate fetal heart rate.
- D. Check for pain relief.
Correct Answer: B
Rationale: Maternal blood pressure monitoring is essential to detect and manage hypotension, a common side effect of epidural anesthesia.
The nurse is educating a client about iron supplements during pregnancy. Which statement indicates understanding?
- A. I should take the supplement with milk to improve absorption.
- B. I should take the supplement with orange juice to improve absorption.
- C. I can stop taking the supplement when I feel better.
- D. I should only take the supplement if I feel fatigued.
Correct Answer: B
Rationale: Vitamin C in orange juice enhances iron absorption, improving its efficacy.