Nokea
Which fetal structure is responsible for carrying oxygenated blood from the placenta to the fetus?
- A. Ductus arteriosus
- B. Umbilical artery
- C. Portal vein
- D. Umbilical vein
Correct Answer: D
Rationale: The correct answer is D: Umbilical vein. The umbilical vein carries oxygenated blood from the placenta to the fetus. This is because the placenta acts as the organ of gas exchange during fetal development. Oxygenated blood from the mother is transferred to the fetus through the umbilical vein. The other choices are incorrect because: A) Ductus arteriosus is a fetal blood vessel that connects the pulmonary artery to the aorta, bypassing the lungs. B) Umbilical artery carries deoxygenated blood from the fetus to the placenta. C) Portal vein carries nutrient-rich blood from the intestines to the liver, not from the placenta to the fetus.
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A client is admitted to the hospital with severe pregnancy-induced hypertension (PIH). The physician orders magnesium sulfate. Which nursing intervention is important when administering this drug?
- A. Assess blood pressure and respiratory rate every fifteen minutes
- B. Monitor blood glucose levels every eight hours
- C. Evaluate for orthostatic hypotension when getting the client up to walk
- D. Observe for premature labor every shift
Correct Answer: A
Rationale: The correct answer is A because magnesium sulfate is a central nervous system depressant used to prevent seizures in PIH. It can cause respiratory depression and hypotension. Assessing blood pressure and respiratory rate every fifteen minutes is crucial to monitor for signs of magnesium toxicity and ensure the client's safety. Monitoring blood glucose levels (B) is not directly related to magnesium sulfate administration. Evaluating for orthostatic hypotension (C) and observing for premature labor (D) are not specific to the administration of magnesium sulfate in treating PIH.
A nurse is caring for a prenatal client who has parvovirus B19 (fifth disease). Which of the following actions should the nurse take?
- A. Administer antiviral medication
- B. Schedule an ultrasound examination
- C. Administer Haemophilus influenza type b vaccine
- D. Schedule an indirect Coombs’ test
Correct Answer: B
Rationale: The correct answer is B: Schedule an ultrasound examination. Parvovirus B19 in pregnancy can lead to complications such as fetal hydrops. An ultrasound can monitor fetal well-being and detect any abnormalities. Administering antiviral medication (A) is not typically recommended for parvovirus B19. Administering the Haemophilus influenza type b vaccine (C) is unrelated to this condition. Performing an indirect Coombs' test (D) is used to detect maternal antibodies in Rh incompatibility, not related to parvovirus B19.
A client reports awaking from sleep by contractions that are occurring every five minutes and lasting 30-40 seconds. Which of the following questions should the nurse ask to assess for true labor versus false labor?
- A. When did your contractions begin?
- B. Have you noticed any bloody show or fluid coming from your vagina?
- C. What happens to your contractions when you move about?
- D. Have you felt fetal movement over the last 24 hours?
Correct Answer: B
Rationale: The correct answer is B. The presence of bloody show or fluid coming from the vagina can indicate ruptured membranes, which is a sign of true labor. This is important in determining whether the client is in active labor. Asking about the presence of bloody show or fluid helps differentiate between true and false labor.
Choice A is less relevant as the timing of contractions alone does not distinguish between true and false labor. Choice C is related to assessing the effectiveness of contractions, not differentiating between true and false labor. Choice D is important for assessing fetal well-being but does not help in distinguishing between true and false labor.
Which assessment finding suggests thrombophlebitis in a postpartum client?
- A. These signs and symptoms are indications of pulmonary embolism.
- B. These signs and symptoms do not relate to thrombophlebitis. Dyspnea, tachypnea, and apprehension
- C. Chills, hypotension, and abdominal tenderness
- D. Positive Homan's sign, calf warmth, and pain
Correct Answer: D
Rationale: The correct answer is D because a positive Homan's sign, calf warmth, and pain are classic signs of thrombophlebitis in a postpartum client. A positive Homan's sign indicates pain in the calf upon dorsiflexion of the foot, which can indicate a blood clot in the leg veins. Calf warmth and pain are also indicative of a possible deep vein thrombosis.
Choices A and B are incorrect because they relate to pulmonary embolism, not thrombophlebitis. Choice C describes signs of sepsis or intra-abdominal pathology, not specifically thrombophlebitis.
In summary, the key indicators of thrombophlebitis in a postpartum client are a positive Homan's sign, calf warmth, and pain, making choice D the correct answer.
In a child diagnosed with Tetralogy of Fallot, which of the following is a compensatory mechanism to decrease venous return to the heart?
- A. Squatting
- B. Clubbing
- C. Shortness of breath
- D. Polycythemia
Correct Answer: A
Rationale: Squatting is a compensatory mechanism that decreases venous return (deoxygenated blood) to the heart. This clinical sign is commonly seen in young children with Tetralogy of Fallot, a type of cyanotic heart disease. Squatting helps reduce the workload on the heart by decreasing the amount of deoxygenated blood returning to it.