Nokea
Which complication of adolescent pregnancy should the nurse plan to monitor?
- A. Anemia
- B. Placenta previa
- C. Abruptio placenta
- D. Incompetent cervix
Correct Answer: D
Rationale: Incompetent cervix, also known as cervical insufficiency, is a condition where the cervix begins to dilate and efface prematurely due to weak cervical tissue. This can lead to late miscarriage or preterm birth. Adolescent mothers are at a higher risk for this complication due to their immature reproductive systems. Therefore, the nurse should plan to monitor for signs and symptoms of incompetent cervix in adolescent pregnant clients to prevent adverse maternal and fetal outcomes. Anemia, placenta previa, and abruptio placenta are other potential complications of pregnancy, but they are not specifically associated with adolescent pregnancy.
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The nurse is assessing a client diagnosed with placenta previa. Which findings should the nurse expect to note?
- A. Uterine rigidity.
- B. Severe abdominal pain.
- C. Bright red vaginal bleeding.
- D. Soft, relaxed, nontender uterus.
Correct Answer: C
Rationale: Placenta previa presents as painless bright red bleeding and a soft, non-tender uterus.
During which stage of the menstrual cycle does the endometrium layer thicken?
- A. Proliferative phase
- B. Ovulation phase
- C. Luteal phase
- D. Secretory phase
Correct Answer: D
Rationale: The endometrium layer thickens during the secretory phase of the menstrual cycle. This phase occurs after ovulation and is characterized by the endometrium preparing for possible implantation of a fertilized egg by further thickening and becoming more vascularized. If pregnancy does not occur, the thickened endometrial lining will be shed during menstruation. The secretory phase is under the control of the hormone progesterone, which is produced by the corpus luteum formed in the ovary after ovulation.
What two steps of the CJMM are included in the assessment step of the nursing process?
- A. noticing cues and evaluating outcomes
- B. analyzing cues and generating solutions
- C. noticing and analyzing cues
- D. analyzing cues and taking action
Correct Answer: A
Rationale: In the assessment step of the nursing process, two steps of the CJMM (Clinical Judgment Model) that are included are noticing cues and evaluating outcomes. Noticing cues involves observing and recognizing relevant information or data related to the patient's health status, while evaluating outcomes involves assessing the effectiveness of the nursing interventions and patient responses to the care provided. By noticing cues, nurses gather information that guides their decision-making process, and by evaluating outcomes, they determine the impact of their actions on the patient's health and adjust the plan of care as needed. These two steps are essential in the assessment phase as they contribute to developing a comprehensive understanding of the patient's needs and progress towards achieving desired health outcomes.
A newborn is delivered vaginally in the breech presentation. When examining her baby, the mother asks if the baby has been injured during birth because of the large black and blue areas on the buttocks and legs, The nurse should respond that:
- A. This is not a birth injury probably just a birthmark
- B. These are caused by forceps used to aid in the delivery of the baby
- C. This a temporary complication that will disappear in about a week
- D. These Mongolian spots, common in dark-skinned babies, disappear within a year
Correct Answer: A
Rationale: The large black and blue areas on the buttocks and legs of the newborn are likely Mongolian spots. Mongolian spots are common in infants with dark skin and are not a result of birth trauma. They are benign birthmarks caused by pigment that did not make it to the top layer of the skin before birth. These spots typically fade over time and may disappear completely within a few years. It is important to educate parents about Mongolian spots to alleviate any concerns they may have about their baby's skin markings.
The laboring person asks the nurse to review the birth plan. What item is on a typical birth plan?
- A. where the patient will be staying after birth
- B. who will be watching their other children
- C. what position they want to birth in
- D. how they will time contractions
Correct Answer: C
Rationale: Birth plans often include preferences for birthing positions to promote comfort and effectiveness.