Nokea
A nurse is assessing a client who is in active labor and notes that the presenting part is at 0 station. Which of the following is the correct interpretation of this clinical finding?
- A. The fetal head is in the left occiput posterior position.
- B. The largest fetal diameter has passed through the pelvic outlet.
- C. The posterior fontanel is palpable.
- D. The lowermost portion of the fetus is at the level of the ischial spines.
Correct Answer: D
Rationale: Correct Answer: D. The lowermost portion of the fetus is at the level of the ischial spines.
Rationale:
1. Station 0 indicates the presenting part of the fetus is at the level of the ischial spines.
2. This position is significant as it helps determine the progress of labor.
3. It means the fetus has not descended into the birth canal yet, indicating early labor stages.
Summary:
A: Incorrect. Left occiput posterior position is related to fetal head position, not station.
B: Incorrect. Passing through the pelvic outlet refers to engagement, not station.
C: Incorrect. The posterior fontanel being palpable is not directly related to station.
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What must instructions for use of nonoxynol-9 spermicide include?
- A. Nononxynol-9 used with barrier methods increases their efficacy.
- B. When spermicide is used with condoms, it will further decrease the risk of STIs.
- C. Remove excess spermicide from the vagina within 6 hours to reduce vaginal irritation.
- D. Place the spermicide close to the opening of the vagina for maximal effectiveness.
Correct Answer: C
Rationale: The correct answer, C, states that excess spermicide should be removed from the vagina within 6 hours to reduce vaginal irritation. This is important as leaving excess spermicide can lead to discomfort and irritation. It is a crucial instruction to ensure the user's comfort and safety.
Choice A is incorrect as nonoxynol-9 does not necessarily increase efficacy when used with barrier methods.
Choice B is incorrect because while using spermicide with condoms can reduce the risk of STIs, the statement does not specifically address the instructions for use.
Choice D is incorrect as placing the spermicide close to the vagina's opening does not guarantee maximal effectiveness and is not a critical instruction for safe use.
A 28-year-old primigravida admitted to antepartum unit with a diagnosis of hyperemesis gravidarum. Nursing care is based on which of the following?
- A. Assess for dehydration and starvation
- B. Isolated from family
- C. This condition is caused by psychogenic factor
- D. Similar to morning sickness
Correct Answer: A
Rationale: Rationale for Correct Answer (A): Assessing for dehydration and starvation is crucial in managing hyperemesis gravidarum, as it can lead to serious complications for both the mother and the fetus. Dehydration can result from persistent vomiting and may require intravenous fluids. Starvation can occur due to poor nutrient intake. Monitoring these factors helps in providing appropriate treatment and preventing further health issues.
Summary of Incorrect Choices:
B: Isolating the patient from family is not necessary and can have negative psychological impacts. Support from family is crucial in managing hyperemesis gravidarum.
C: Hyperemesis gravidarum is a physical condition related to pregnancy, not a psychogenic factor.
D: Hyperemesis gravidarum is more severe and persistent than morning sickness, requiring different management strategies.
The nurse provides education to the person undergoing a surgical abortion. What response by the person shows an understanding of the education?
- A. “It’s good I won’t have any pain after the procedure.â€
- B. “I think I’m sure about my decision.â€
- C. “I should call if I soak a pad in 2 hours.â€
- D. “I should follow up for contraception counseling at my annual exam in 6 months.â€
Correct Answer: C
Rationale: The correct answer is C because soaking a pad in 2 hours could indicate excessive bleeding, a potential complication after a surgical abortion. This response shows understanding of the education provided by the nurse about when to seek immediate medical attention.
Choice A is incorrect because it is not true that there will be no pain after a surgical abortion; pain is a common experience post-procedure. Choice B is incorrect because it does not demonstrate an understanding of the key information provided during education. Choice D is incorrect because contraception counseling should be addressed sooner than 6 months post-abortion to prevent unintended pregnancies.
A 28-year-old patient has decided to use the patch contraception. The nurse is educating her on the best site to use. Where is the best place to put the patch? Select all that apply.
- A. Buttocks
- B. Neck
- C. Leg
- D. Arm
Correct Answer: B
Rationale: The correct answer is B: Neck. The patch contraception is most effective when applied to a clean, dry, and hairless area of the body. The neck is a suitable site because it is easily accessible, non-occlusive, and less likely to be affected by clothing friction. Placing the patch on the neck also helps avoid skin irritation and allows for optimal absorption of hormones.
Choice A: Buttocks - The buttocks may not be an ideal site as it can be covered by clothing and may not allow for proper adherence and absorption.
Choice C: Leg - The leg is not typically recommended as a site for the patch due to movement and friction from clothing that may affect patch adhesion and hormone absorption.
Choice D: Arm - While the arm is a possible site for the patch, it is not as ideal as the neck because it may be subject to more movement and rubbing against clothing, potentially affecting patch adherence and effectiveness.
While evaluating the reflexes of the newborn, the nurse notes that with a loud noise the newborn symmetrically abduct and extend his arms, his fingers fan out and forms a c with the thumb and forefinger. What does the nurse document?
- A. Positive Moro reflex
- B. Positive Babinski reflex
- C. Rooting reflex
- D. Tonic neck reflex
Correct Answer: A
Rationale: The correct answer is A: Positive Moro reflex. The Moro reflex is elicited by a sudden loud noise or a jarring movement. The newborn symmetrically abducts and extends their arms, followed by fanning out their fingers and forming a "C" shape with the thumb and forefinger. This reflex is an involuntary response that indicates the normal development of the newborn's nervous system. The other choices are incorrect because:
B: Positive Babinski reflex is elicited by stroking the sole of the foot, resulting in the toes fanning out and big toe dorsiflexing.
C: Rooting reflex is elicited by touching the newborn's cheek, causing them to turn their head towards the stimulus and open their mouth to seek food.
D: Tonic neck reflex is elicited by turning the newborn's head to one side, causing extension of the arm on that side and flexion of the opposite arm.