Nokea
Which factor should alert the nurse for the potential of a prolapsed umbilical cord?
- A. Presenting part at station minus 3 (too much empty space in between)
- B. Meconium stained amniotic fluid
- C. Pregnancy at 38 weeks' gestation
- D. Oligohydramnios
Correct Answer: A
Rationale: A presenting part at station minus 3 indicates that there is too much empty space between the presenting part (usually the fetus's head) and the pelvic inlet. This increased space raises the potential for the umbilical cord to prolapse through the cervix and into the birth canal ahead of the baby, especially when the membranes rupture. A prolapsed umbilical cord is a severe obstetric emergency that can cause fetal compromise due to umbilical cord compression and compromise of blood flow. It requires immediate intervention to relieve the pressure on the cord and increase the likelihood of a safe delivery. Therefore, a presenting part at station minus 3 should alert the nurse to the potential of a prolapsed umbilical cord.
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The nurse is providing discharge teaching to a 20-year-old mother who has had her first male child. Which statement by the mother demonstrates that she understands the discharge teaching regarding his circumcision?
- A. I will observe the whitish-yellow drainage on his penis, but I will not remove it.
- B. I will bring him back to the clinic in 3 days to have the drainage removed.
- C. I will use antibiotic ointment on his penis with every diaper change.
- D. I will rub the area briskly with a washcloth to remove the drainage.
Correct Answer: A
Rationale: Whitish-yellow drainage is normal and should not be removed.
Which data must the nurse consider before administering Depo-Provera (medroxyprogesterone acetate) to a postpartum client?
- A. The capsule must be taken at the same time each day.
- B. The client must be taught to use sunscreen whenever in the sunlight.
- C. The medicine is contraindicated if the woman has lung or esophageal cancer.
- D. The client must use an alternate form of birth control for the first two months.
Correct Answer: C
Rationale: Medroxyprogesterone acetate is contraindicated in women with certain cancers.
A nurse is admitting a client who is at 35 weeks of gestation and is experiencing mild vaginal bleeding due to placenta previa. Which of the following actions should the nurse plan to take?
- A. Initiate continuous monitoring of the FHR.
- B. Administer a dose of betamethasone.
- C. Check the cervix for dilation every 8 hr.
- D. Request that the provider prescribe misoprostol PRN.
Correct Answer: A
Rationale: In placenta previa, the placenta partially or completely covers the cervix, which can lead to vaginal bleeding. Continuous monitoring of the fetal heart rate (FHR) is crucial in this situation to assess the well-being of the fetus. Any signs of distress or changes in the FHR can indicate potential complications, such as fetal hypoxia. This monitoring allows for prompt intervention if necessary to ensure the safety of both the mother and the baby. Administering betamethasone may be indicated to promote fetal lung maturity in cases of anticipated preterm birth, but it is not the priority in this scenario where monitoring the fetal well-being is crucial. Checking the cervix for dilation every 8 hours is not necessary and may increase the risk of further bleeding. Misoprostol, a medication used to induce labor, is contraindicated in cases of placenta previa because it can cause further
A patient would like to use the calendar method for contraception. She has charted her menstrual cycles for several months. Her longest menstrual cycle was 39 days long, and her shortest period was 29 days long. The nurse educates the patient to avoid condomless intercourse during what range of days of the cycle?
- A. day 9 through day 19
- B. day 10 through day 15
- C. day 12 through day 16
- D. day 11 through day 28
Correct Answer: B
Rationale: In the calendar method of contraception, a woman tracks her menstrual cycle to determine the fertile window in which she is most likely to conceive. The fertile window is typically considered to be the days leading up to and including ovulation.
What nursing intervention is appropriate for a woman diagnosed with syphilis?
- A. Council the woman about how to live with a chronic infection.
- B. Question the woman regarding symptoms of other sexually transmitted infections.
- C. Assist the primary health care practitioner with cryotherapy procedures.
- D. Educate the woman regarding the safe disposal of menstrual pads.
Correct Answer: B
Rationale: Syphilis often coexists with other STIs, so questioning is important.