Nokea
Which response by the nurse is correct concerning the legal threshold of viability?
- A. It is usually estimated to be 36 to 40 weeks.
- B. It is usually estimated to be 30 to 35 weeks.
- C. It is usually estimated to be 20 to 24 weeks.
- D. It is usually estimated to be 10 to 15 weeks.
Correct Answer: C
Rationale: The legal threshold of viability is typically 20-24 weeks, when a fetus may survive outside the womb with medical support.
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The laboring client suddenly experiences a dramatic drop in the FHR from the 150s to the 110s. A vaginal exam reveals the presence of the fetal cord protruding through the cervix. What should be the nurse’s first intervention?
- A. Put continuous pressure on the presenting part to keep it off the cord
- B. Place the bed in Trendelenburg position
- C. Insert a urinary catheter and instill saline
- D. Continue to monitor the FHR
Correct Answer: A
Rationale: The nurse should first exert continuous pressure on the presenting part to prevent further cord compression. This is continued until birth, which is usually by cesarean section. The bed should be placed in Trendelenburg position to further prevent pressure on the cord, but only after pressure is placed on the presenting part. A catheter may be inserted and 500 mL of warmed saline instilled to help float the head and prevent further compression, but only after pressure is placed on the presenting part. The fetus is continually monitored throughout until birth.
Which client is at highest risk for ectopic pregnancy?
- A. A client with a history of pelvic inflammatory disease
- B. A client with a normal ultrasound
- C. A client with regular menstrual cycles
- D. A client taking prenatal vitamins
Correct Answer: A
Rationale: Pelvic inflammatory disease increases the risk of ectopic pregnancy by causing tubal scarring, which can impede embryo passage.
The client at 31 weeks’ gestation is diagnosed with mild preeclampsia and placed on home management. What information should the nurse include when providing home management instructions? Select all that apply.
- A. “Plan for hospitalization when nearing 36 weeks’ gestation.”
- B. “Weigh daily and inform the HCP of a sudden increase in weight.”
- C. “Home care will be consulted to take your blood pressure (BP) daily.”
- D. “Perform stretching and range-of-motion exercises twice daily.”
- E. “Rest as much as possible, especially in the lateral recumbent position.”
Correct Answer: B,D,E
Rationale: A sudden weight gain could indicate that the mild preeclampsia is uncontrolled and the client is retaining fluid. The HCP should be consulted. Stretching and ROM exercises can help prevent thrombophlebitis and venous stasis. The lateral recumbent position improves uteroplacental blood flow, reduces maternal BP, and promotes diuresis. A diagnosis of mild preeclampsia does not require hospitalization during the antepartum period unless home management fails to reduce the client’s BP, or other complications occur. BP monitoring every 4 to 6 hours is recommended for the client with mild preeclampsia, but the BP can be taken by the client and does not require a consult with home care.
The nurse practitioner informs the new nurse that the laboring client’s monitor is showing prolonged decelerations. Which interpretation by the new nurse is correct?
- A. The monitor pattern is U or V shaped, with a decrease in FHR to less than 70 beats/minute (bpm), lasting more than 60 seconds.
- B. The FHR shows an episodic or periodic acceleration that lasts 2 minutes or more but less than 10 minutes in duration.
- C. There is an FHR decrease of 15 bpm or more below baseline occurring for at least 2 but not more than 10 minutes.
- D. The mother’s heart rate is exhibiting intermittent or transient deviations or changes from the baseline heart rate.
Correct Answer: C
Rationale: A prolonged deceleration occurs when the FHR decreases 15 bpm or more below baseline for at least 2 but not more than 10 minutes. The prolonged deceleration may resolve spontaneously or with the aid of interventions. A U- or V-shaped pattern with abrupt decrease in the FHR to less than 70 bpm, lasting more than 60 seconds, describes variable (not prolonged) deceleration typically associated with cord compression. Any episodic or periodic acceleration of FHR that lasts 2 minutes or more but less than 10 minutes in duration describes prolonged acceleration, not deceleration. The fetal heart monitor is monitoring the FHR and not the mother’s heart rate.
When teaching the class about varicose veins, which symptom should the nurse instruct clients to report immediately?
- A. The appearance of additional varicose veins
- B. Varicose veins that are purple in color
- C. Legs that begin to ache and feel heavy
- D. Calves that become red, tender, and warm
Correct Answer: D
Rationale: Red, tender, warm calves may indicate deep vein thrombosis, a serious condition requiring immediate reporting.