Nokea
Which explanation by the nurse correctly describes the occurrence of identical twins?
- A. Two separate ova are fertilized by identical sperm.
- B. The mother releases two identical ova.
- C. One fertilized ovum divides into two identical halves.
- D. Two identical ova are fertilized by two identical sperm.
Correct Answer: C
Rationale: Identical twins result from one fertilized ovum splitting into two identical embryos, sharing the same genetic material.
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The client tells the nurse, “Most days, I am so happy I am pregnant, but other days, I am not sure that I am ready to have a baby.” Which is the most accurate response from the nurse?
- A. “This is such a happy time in your life. You need to be optimistic to feel happy.”
- B. “How does your spouse feel about the pregnancy? I hope he is happy about the baby.”
- C. “Feeling differently from day to day is normal. How do you feel today?”
- D. “Why do you feel this way? Is there something I can do to make it better for you?”
Correct Answer: C
Rationale: It is most therapeutic to acknowledge the client’s feelings and probe for more information on her thoughts and feelings about the pregnancy. Not all clients consider pregnancy a happy time in their lives, and the nurse should never tell the client how to feel. The nurse should not divert the client’s concerns away from self by bringing up the father’s adaptation to the pregnancy, even though paternal adaptation is related to maternal adaptation. The client may not be able to identify why she has the feelings she is experiencing or how the nurse can make her feel better. This response does not provide an avenue for further exploration of the client’s concerns.
The nurse informs the pregnant client that her laboratory test indicates she has iron-deficiency anemia. Based on this diagnosis, the nurse should monitor this client for which problems? Select all that apply.
- A. Susceptibility to infection
- B. Easily fatigued
- C. Increased risk for preeclampsia
- D. Increased risk of diabetes
- E. Congenital defects
Correct Answer: A,B,C
Rationale: Iron-deficiency anemia is associated with susceptibility to infection because oxygen is not transported effectively. Iron-deficiency anemia is associated with fatigue because oxygen is not transported effectively. Iron-deficiency anemia is associated with risk of preeclampsia because oxygen is not transported effectively. Iron-deficiency anemia is not associated with an increased risk of diabetes. Iron-deficiency anemia is not associated with an increased risk of congenital defects.
The nurse is caring for the 30-weeks-pregnant client who is having contractions every 1½ to 2 minutes with spontaneous rupture of membranes 2 hours ago. Her cervix is 8 cm dilated and 100% effaced. The nurse determines that delivery is imminent. What intervention is the most important at this time?
- A. Administering a tocolytic agent
- B. Providing teaching information on premature infant care
- C. Notifying neonatology of the impending birth
- D. Preparing for a cesarean section birth
Correct Answer: C
Rationale: The most important intervention is to notify the neonatal team of the delivery because the team members will be needed for respiratory support and possible resuscitation. Tocolytic agents, such as nifedipine (Procardia), can be used for short-term intervention to slow down contractions and delay birth, but it is too late to administer a tocolytic agent. Teaching is important but is not appropriate at this time. A cesarean birth is indicated if there are other obstetrical needs.
The nurse is caring for the client who is being evaluated for a suspected malpresentation. The fetus’s long axis is lying across the maternal abdomen, and the contour of the abdomen is elongated. Which should be the nurse’s documentation of the lie of the fetus?
- A. Vertex
- B. Breech
- C. Transverse
- D. Brow
Correct Answer: C
Rationale: A transverse lie occurs in 1 in 300 births and is marked by the fetus’s lying in a side-lying position across the abdomen. Vertex presentations result in the lie’s being vertical. Breech presentations result in the lie’s being vertical. A brow presentation is also a vertical lie.
The nurse is preparing to administer 2 mg hydromorphone hydrochloride to the client who is 28 hours post—cesarean section. The medication available is in a concentration of 4 mg/mL. How many milliliters should the nurse administer?
- A. 0.5 mL
- B. 1.0 mL
- C. 2.0 mL
- D. 4.0 mL
Correct Answer: 0.5 mL
Rationale: (2 mg / 4 mg) x 1 mL = 0.5 mL. The nurse should administer 0.5 mL hydromorphone hydrochloride (Dilaudid).