Nokea
When is the earliest interval that chorionic villus sampling (CVS) can be performed during pregnancy?
- A. 4 weeks
- B. 8 weeks
- C. 10 weeks
- D. 14 weeks
Correct Answer: C
Rationale: CVS is typically performed between 10 and 13 weeks of gestation to analyze fetal tissue for chromosomal, metabolic, or DNA abnormalities.
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A postpartum person is experiencing a headache after delivery. What is the most appropriate initial nursing action?
- A. administer pain medication
- B. monitor blood pressure
- C. perform a neurological assessment
- D. provide oxygen to the person
Correct Answer: B
Rationale: The correct initial action is to monitor blood pressure (B) because postpartum headache could indicate preeclampsia, a serious condition characterized by high blood pressure. Monitoring blood pressure is crucial to assess for signs of preeclampsia. Administering pain medication (A) may mask symptoms, performing a neurological assessment (C) may not address the underlying cause, and providing oxygen (D) is not the priority without knowing the cause of the headache.
A woman delivers a fetal demise that has lanugo covering the entire body, nails that are present on the fingers and toes, but eyes that are still fused. Prior to the death, the mother stated that she had felt quickening. Based on this information, the nurse knows that the baby is about how many weeks’ gestation?
- A. 15 weeks.
- B. 22 weeks.
- C. 29 weeks.
- D. 36 weeks.
Correct Answer: B
Rationale: Lanugo typically appears around 16-20 weeks and covers the entire body by 22-24 weeks. Nails begin forming at around 18-20 weeks and are fully developed by 22 weeks. Fused eyelids occur up until about 24-26 weeks, after which they open. Quickening (feeling of fetal movement) usually occurs between 18-22 weeks in first-time pregnancies. Therefore, the most likely gestational age is 22 weeks.
A pregnant woman weighs 90.9 kg. The nurse is educating the patient on complications that the patient may be at risk for during pregnancy. Which response by the patient indicates that she understands?
- A. Due to my weight, there is a possibility that I may develop gestational diabetes.
- B. I am not overweight, but I am still at risk for gestational diabetes.
- C. My mother had preeclampsia during one of her pregnancies.
- D. I will need to do a glucose tolerance test in my second trimester.
Correct Answer: A
Rationale: The correct answer is A because maternal obesity is a risk factor for gestational diabetes. The patient's weight of 90.9 kg puts her at an increased risk. Gestational diabetes is more likely to occur in overweight or obese pregnant women. The patient's understanding that her weight increases the possibility of developing gestational diabetes demonstrates comprehension of the risk factors.
Choice B is incorrect because weight alone is a significant risk factor for gestational diabetes, regardless of whether the patient is considered overweight or not.
Choice C is incorrect as a family history of preeclampsia is a risk factor for preeclampsia, not gestational diabetes.
Choice D is incorrect because while a glucose tolerance test may be part of prenatal care, it does not specifically address the patient's understanding of the risk factors associated with her weight and gestational diabetes.
When assessing the fruit intake of a pregnant client, the nurse notes that the client usually eats 1 piece of fruit per day and drinks a 12 oz glass of fruit juice per day. Which of the following is the most important communication for the nurse to make?
- A. You are effectively meeting your daily fruit requirements.
- B. Fruit juices are excellent sources of folic acid.
- C. It would be even better if you were to consume more whole fruits and less fruit juice.
- D. Your fruit intake far exceeds the recommended daily fruit intake.
Correct Answer: C
Rationale: Whole fruits provide fiber and additional nutrients compared to fruit juices, which may contain added sugars. Encouraging increased consumption of whole fruits aligns with healthy dietary guidelines for pregnancy.
A nurse is monitoring a laboring person who is receiving oxytocin for labor induction. What is the priority assessment during oxytocin infusion?
- A. monitor fetal heart rate
- B. assess maternal vital signs
- C. assess uterine tone
- D. monitor for signs of uterine hyperstimulation
Correct Answer: C
Rationale: The correct answer is C: assess uterine tone. This is the priority assessment during oxytocin infusion because oxytocin can cause uterine hyperstimulation, leading to fetal distress. By assessing uterine tone regularly, the nurse can detect any signs of hyperstimulation early and take appropriate action to prevent complications. Monitoring fetal heart rate (A) is important but assessing uterine tone takes precedence as it directly impacts fetal well-being. Maternal vital signs (B) are important but are not as directly related to the safety of the fetus during oxytocin infusion. Monitoring for signs of uterine hyperstimulation (D) is essential, but assessing uterine tone is the proactive approach to detect hyperstimulation before it escalates.