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What is the primary purpose of a vaginal examination during the second stage of labor?
- A. to assess fetal descent
- B. to evaluate uterine progress
- C. to assess cervical dilation
- D. to assess fetal position
Correct Answer: B
Rationale: The correct answer is B because during the second stage of labor, the primary purpose of a vaginal examination is to evaluate uterine progress. This is important to determine the effectiveness of contractions and the progression of labor. Assessing fetal descent (A) is typically done during the first stage of labor. Assessing cervical dilation (C) is important throughout labor but is not the primary purpose during the second stage. Assessing fetal position (D) can also be important but is not the primary focus during the second stage.
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What is the most common site for fertilization?
- A. Lower segment of the uterus
- B. Outer third of the fallopian tube near the ovary
- C. Upper portion of the uterus
- D. Area of the fallopian tube farthest from the ovary
Correct Answer: B
Rationale: Fertilization takes place in the outer third of the fallopian tube, which is closest to the ovary.
The nurse is caring for a 16-year-old patient who is 32 weeks pregnant with her first child, who is male. The patient's mother has accompanied her to today's visit. During the nursing assessment, the patient mentions that she is no longer in a relationship with the baby's father but her mother plans to help her. However, the patient's mother asks whether this will have any impact on the child. Which should the nurse indicate the child is at increased risk of during his adolescence?
- A. Hypertension
- B. Diabetes
- C. Alcohol abuse
- D. Intraventricular bleeding
Correct Answer: C
Rationale: The correct answer is C: Alcohol abuse. During adolescence, children of parents who have substance abuse issues, like alcohol, are at an increased risk of developing similar problems. This is due to genetic predisposition, environmental factors, and learned behavior. Children tend to model the behavior of their parents, and if they are exposed to alcohol abuse at a young age, they are more likely to engage in alcohol abuse themselves as they grow older.
Incorrect choices:
A: Hypertension - This choice is not directly related to the situation described and is not typically a risk factor associated with parental alcohol abuse.
B: Diabetes - Similar to choice A, diabetes is not directly linked to parental alcohol abuse and is not a common risk factor during adolescence in this scenario.
D: Intraventricular bleeding - This is a medical condition that is not typically influenced by parental alcohol abuse and is not a common risk factor during adolescence.
The nurse midwife tells a client that the baby is growing and that ballottement was evident during the vaginal examination. How should the nurse explain what the nurse midwife means by ballottement?
- A. The nurse midwife saw that the mucous plug was intact.
- B. The nurse midwife felt the baby rebound after being pushed.
- C. The nurse midwife palpated the fetal parts through the uterine wall.
- D. The nurse midwife assessed that the baby is head down.
Correct Answer: B
Rationale: Ballottement is the rebound of the fetus when it is pushed during a vaginal examination, indicating fetal movement and growth.
A birthing person who delivered a newborn vaginally is receiving care in the labor and birth unit. The health-care provider diagnosed a retained placenta. What is the primary risk associated with a retained placenta?
- A. neonatal jaundice
- B. postpartum hemorrhage
- C. delayed bonding
- D. postpartum anemia
Correct Answer: B
Rationale: The primary risk associated with a retained placenta is postpartum hemorrhage. When the placenta does not deliver completely after childbirth, it can lead to excessive bleeding, risking the mother's health. This condition requires immediate medical attention to prevent severe complications. Neonatal jaundice, delayed bonding, and postpartum anemia are not directly linked to a retained placenta, making them incorrect choices. Neonatal jaundice is caused by elevated bilirubin levels, delayed bonding is related to emotional factors, and postpartum anemia is characterized by low red blood cell count, none of which are the primary risk associated with a retained placenta.
A pregnant patient reports experiencing dizziness and fainting when standing up quickly. What is the nurse's most appropriate response?
- A. Instruct the patient to avoid standing for long periods.
- B. Encourage the patient to increase sodium intake.
- C. Recommend that the patient take frequent naps during the day.
- D. Teach the patient to rise slowly from a sitting or lying position.
Correct Answer: D
Rationale: The correct answer is D: Teach the patient to rise slowly from a sitting or lying position. This response is appropriate because the patient is likely experiencing orthostatic hypotension, which is common during pregnancy due to hormonal changes. Rising slowly helps prevent sudden drops in blood pressure, reducing dizziness and fainting.
A: Instructing the patient to avoid standing for long periods does not address the underlying issue of orthostatic hypotension.
B: Encouraging increased sodium intake may not be necessary and could potentially have negative effects.
C: Recommending frequent naps does not address the immediate problem of orthostatic hypotension when standing up quickly.