Nokea
While the nurse is caring for a neonate at 32 weeks' gestation in an isolette with continuous oxygen administration, the neonate's mother asks why the neonate's oxygen is humidified. The nurse should tell the mother?
- A. The humidity promotes expansion of the neonate's immature lungs.'
- B. The humidity helps to prevent viral or bacterial pneumonia.'
- C. Oxygen is drying to the mucous membranes unless it is humidified.'
- D. Circulation to the baby's heart is improved with humidified oxygen.'
- E. fetal position for a 32-year-old client
Correct Answer: C
Rationale: Humidified oxygen prevents drying of the mucous membranes, which is critical for maintaining airway health in preterm neonates.
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The physician orders intermittent fetal heart rate monitoring for a 20-year-old obese primigravid client at 40 weeks' gestation who is admitted to the birthing center in the first stage of labor. The nurse should monitor the client's fetal heart rate pattern at which of the following intervals?
- A. Every 15 minutes during the latent phase.
- B. Every 30 minutes during the active phase.
- C. Every 60 minutes during the initial phase.
- D. Every 2 hours during the transition phase.
Correct Answer: B
Rationale: For a low-risk primigravid client in the active phase of the first stage of labor, intermittent fetal heart rate monitoring is typically performed every 30 minutes to ensure fetal well-being, as per standard obstetric guidelines. More frequent monitoring (every 15 minutes) is reserved for the second stage or high-risk cases, while less frequent intervals (every 60 minutes or 2 hours) are insufficient for active labor.
After conducting a class for female adolescents about human reproduction, which of the following statements indicates that the school nurse's teaching has been effective?
- A. Under ideal conditions, sperm can reach the ovum in 15 to 30 minutes, resulting in pregnancy.
- B. I won't become pregnant if I abstain from intercourse during the last 14 days of my menstrual cycle.
- C. Both of the above
- D. None of the above
Correct Answer: A
Rationale: Sperm can reach the ovum in 15-30 minutes under ideal conditions, which is accurate. Abstaining during the last 14 days of the cycle is not a reliable contraception method, as ovulation timing varies.
A nurse is counseling a client about the vaginal contraceptive ring. Which of the following client statements indicates a need for further teaching?
- A. I will leave the ring in place for three weeks.
- B. I may experience nausea or breast tenderness.
- C. I can remove the ring for up to 3 hours if needed.
- D. The ring will make my periods heavier.
Correct Answer: D
Rationale: The vaginal contraceptive ring typically reduces menstrual flow or causes lighter periods, not heavier ones. The other statements are correct, indicating a need for further teaching about menstrual effects.
For the client who is receiving intravenous magnesium sulfate for severe preeclampsia, which of the following assessment findings would alert the nurse to suspect hypermagnesemia?
- A. Decreased deep tendon reflexes.
- B. Cool skin temperature.
- C. Rapid pulse rate.
- D. Tingling in the toes.
Correct Answer: A
Rationale: Decreased deep tendon reflexes are a sign of hypermagnesemia.
The nurse assesses a primiparous client in labor for 20 hours. The nurse identifies late decelerations on the monitor and initiates standard procedures for the labor client with this wave pattern. Which intravenous should the nurse perform? Select all that apply.
- A. Administering oxygen via mask to the client.
- B. Questioning the client about the effectiveness of pain relief.
- C. Placing the client on her side.
- D. Readjusting the monitor to a more comfortable position.
- E. Applying an internal fetal monitor to help identify the cause of the decelerations.
Correct Answer: A,C
Rationale: Late decelerations indicate uteroplacental insufficiency. Standard interventions include administering oxygen to improve fetal oxygenation and placing the client on her side to enhance uterine perfusion. Questioning pain relief or readjusting the monitor does not address the issue, and internal monitoring may be considered but is not the first step.