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What is the most critical sign of fetal distress during labor?
- A. Accelerations in fetal heart rate
- B. Decreased variability in fetal heart rate
- C. Early decelerations in fetal heart rate
- D. Late decelerations in fetal heart rate
Correct Answer: D
Rationale: The correct answer is D: Late decelerations in fetal heart rate. Late decelerations indicate uteroplacental insufficiency, where the fetus is not receiving enough oxygen during contractions. This is critical as it can lead to fetal hypoxia and acidosis, posing a risk to the baby's well-being. Early decelerations (C) are generally benign and result from head compression during contractions. Accelerations (A) are a reassuring sign indicating fetal well-being. Decreased variability (B) can be concerning but is not as critical as late decelerations in indicating fetal distress.
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The nurse is educating a client about Braxton Hicks contractions. Which statement indicates proper understanding?
- A. They are regular and increase in intensity over time.
- B. They are irregular and usually painless.
- C. They indicate that labor is starting.
- D. They require immediate medical attention.
Correct Answer: B
Rationale: The correct answer is B because Braxton Hicks contractions are indeed irregular and typically painless contractions that occur throughout pregnancy. They are considered practice contractions and do not indicate the onset of labor. Choice A is incorrect as Braxton Hicks contractions are not regular or increasing in intensity. Choice C is incorrect because Braxton Hicks contractions do not signal the start of labor. Choice D is also incorrect as Braxton Hicks contractions are a normal part of pregnancy and do not require immediate medical attention.
The nursing instructor asks the student to describe fetal circulation, specifically the ductus venosus. Which statement by the student indicates an understanding?
- A. It connects the pulmonary artery to the aorta.
- B. It is an opening between the right and left atria.
- C. It connects the umbilical vein to the inferior vena cava.
- D. It connects the umbilical artery to the inferior vena cava.
Correct Answer: C
Rationale: The correct answer is C because the ductus venosus is a fetal vessel that connects the umbilical vein to the inferior vena cava, allowing oxygenated blood from the placenta to bypass the liver and flow directly to the fetal heart. Choice A is incorrect because the ductus arteriosus connects the pulmonary artery to the aorta. Choice B is incorrect as it refers to the foramen ovale, which is an opening between the right and left atria. Choice D is incorrect as it describes the ductus deferens, a part of the male reproductive system.
A patient 11 weeks' gestation comes to the emergency room department with c/o dizziness, abdominal pain, and shoulder pain. Lab tests reveal a beta-hcg lower than expected level for gestational age
- A. Ultrasound confirms no intrauterine
- B. The nurse knows the most likely diagnostic is an ectopic pregnancy. What statement should the nurse use to explain to the patient?
- C. The baby is in the fallopian tube, the tube has ruptured and is causing bleeding
Correct Answer: B
Rationale: Step 1: Recognize Symptoms - Dizziness, abdominal pain, shoulder pain, low beta-hcg.
Step 2: Consider Ectopic Pregnancy - Symptoms align with ectopic pregnancy.
Step 3: Rule Out Miscarriage - Low beta-hcg indicates not viable intrauterine pregnancy (Choice A).
Step 4: Understand Ectopic Pregnancy - Explaining ectopic pregnancy (Choice C) and rupture to patient may cause distress.
Step 5: Communicate - Nurse should use simple, empathetic statement (Choice B) to explain the likely diagnosis.
Summary: Choice B is correct as it addresses the likely diagnosis without causing undue distress to the patient, unlike Choices A and C which may lead to confusion and anxiety.
A nurse is a prenatal clinic is completing a skin assessment for a pregnant client in the second trimester. Which clinical findings should the nurse expect (select all that apply)?
- A. Eczema
- B. Psoriasis C.Linea nigra
- C. Chloasma
- D. Striae gravidarum C, D, E
Correct Answer: C
Rationale: The correct answer is C: Linea nigra. During the second trimester of pregnancy, hormonal changes can lead to the development of Linea nigra, a dark vertical line that appears on the abdomen. This is a common skin change in pregnant women.
Explanation:
1. Eczema (choice A) and Psoriasis (choice B) are chronic skin conditions that are not typically associated with pregnancy. These conditions are not expected findings during the second trimester.
2. Chloasma (choice C) is also known as the "mask of pregnancy" and presents as dark patches on the face. This is a common skin change during pregnancy, especially in the second trimester.
3. Striae gravidarum (choice D) are stretch marks that may develop on the abdomen, breasts, and thighs during pregnancy. While this is a common skin change in pregnancy, it is not one of the expected findings in the second trimester according to the question.
In summary, the correct
The nurse should designate the highest priority health outcomes to be:
- A. Oxygenation will remain adequate
- B. Body temperature will remain stable
- C. Weight will increase by 30g per day
- D. Heart rate will recover to an acceptable range
Correct Answer: A
Rationale: The correct answer is A because adequate oxygenation is a critical health outcome necessary for cellular function and overall well-being. Without sufficient oxygenation, other bodily functions can be compromised. Stable body temperature (B) is important but not as immediately life-threatening as inadequate oxygenation. Weight gain (C) is not a priority health outcome in this scenario. Heart rate recovery (D) is important but ensuring adequate oxygenation takes precedence in this case.