Which of the following would be the nurse’s most appropriate response to a client who asks why she must have a cesarean delivery if she has a complete placenta previa?
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Solution
“The placenta is covering the opening of the uterus and blocking your baby.”
A complete placenta previa occurs when the placenta covers the opening of the uterus, thus blocking the passageway for the baby. This response explains what a complete previa is and the reason the baby cannot come out except by cesarean delivery.
Option A: Telling the client to ask the physician is a poor response and would increase the patient’s anxiety.
Option B: Although a cesarean would help to prevent hemorrhage, the statement does not explain why the hemorrhage could occur.
Option C: With a complete previa, the placenta is covering all the cervix, not just most of it.
A multigravida at 38 weeks’ gestation is admitted with painless, bright red bleeding and mild contractions every 7 to 10 minutes. Which of the following assessments should be avoided?
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Solution
Cervical dilation
The signs indicate placenta previa and vaginal exam to determine cervical dilation would not be done because it could cause hemorrhage.
Option A: Assessing maternal vital signs can help determine maternal physiologic status.
Option B: Fetal heart rate is important to assess fetal well-being and should be done.
Option C: Monitoring the contractions will help evaluate the progress of labor.
After 4 hours of active labor, the nurse notes that the contractions of a primigravida client are not strong enough to dilate the cervix. Which of the following would the nurse anticipate doing?
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Solution
Obtaining an order to begin IV oxytocin infusion
The client’s labor is hypotonic. The nurse should call the physical and obtain an order for an infusion of oxytocin, which will assist the uterus to contract more forcefully in an attempt to dilate the cervix.
Option B: Administering light sedative would be done for hypertonic uterine contractions.
Option C: Preparing for cesarean section is unnecessary at this time.
Option D: Oxytocin would increase the uterine contractions and hopefully progress labor before a cesarean would be necessary. It is too early to anticipate client pushing with contractions.
During a prenatal class, the nurse explains the rationale for breathing techniques during preparation for labor based on the understanding that breathing techniques are most important in achieving which of the following?
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Solution
Facilitate relaxation, possibly reducing the perception of pain
Breathing techniques can raise the pain threshold and reduce the perception of pain. They also promote relaxation.
Options A, B, and D: Breathing techniques do not eliminate pain, but they can reduce it. Positioning, not breathing, increases uteroplacental perfusion.
During a pelvic exam, the nurse notes a purple-blue tinge of the cervix. The nurse documents this as which of the following?
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Solution
Chadwick’s sign
Chadwick’s sign refers to the purple-blue tinge of the cervix.
Option A: Braxton Hicks contractions are painless contractions beginning around the 4th month.
Option C: Goodell’s sign indicates softening of the cervix.
Option D: Flexibility of the uterus against the cervix is known as McDonald’s sign.
The nurse documents positive ballottement in the client’s prenatal record. The nurse understands that this indicates which of the following?
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Solution
Passive movement of the unengaged fetus
Ballottement indicates passive movement of the unengaged fetus.
Option A: Ballottement is not a contraction.
Option C: Fetal kicking felt by the client represents quickening.
Option D: Enlargement and softening of the uterus is known as Piskacek’s sign.
A client at 8 weeks’ gestation calls complaining of slight nausea in the morning hours. Which of the following client interventions should the nurse question?
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Solution
Taking 1 teaspoon of bicarbonate of soda in an 8-ounce glass of water.
Using bicarbonate would increase the amount of sodium ingested, which can cause complications.
Option B: Eating low-sodium crackers would be appropriate.
Option C: Since liquids can increase nausea avoiding them in the morning hours when nausea is usually the strongest is appropriate.
Option D: Eating six small meals a day would keep the stomach full, which often decrease nausea.
To differentiate as a female, the hormonal stimulation of the embryo that must occur involves which of the following?
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Solution
Secretion of estrogen by the fetal gonad
The fetal gonad must secrete estrogen for the embryo to differentiate as a female.
Option A: An increase in maternal estrogen secretion does not effect differentiation of the embryo, and maternal estrogen secretion occurs in every pregnancy.
Option B: Maternal androgen secretion remains the same as before pregnancy and does not affect differentiation.
Option C: Secretion of androgen by the fetal gonad would produce a male fetus.
When performing a pelvic examination, the nurse observes a red swollen area on the right side of the vaginal orifice. The nurse would document this as enlargement of which of the following?
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Solution
Bartholin’s gland
Bartholin’s glands are the glands on either side of the vaginal orifice.
Option A: The clitoris is female erectile tissue found in the perineal area above the urethra.
Option B: The parotid glands are open into the mouth.
Option C: Skene’s glands open into the posterior wall of the female urinary meatus.
When preparing to administer the vitamin K injection to a neonate, the nurse would select which of the following sites as appropriate for the injection?
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Solution
Vastus lateralis muscle
The middle third of the vastus lateralis is the preferred injection site for vitamin K administration because it is free of blood vessels and nerves and is large enough to absorb the medication.
Option A: The deltoid muscle of a newborn is not large enough for a newborn IM injection. Injections into this muscle in a small child might cause damage to the radial nerve.
Option B: The anterior femoris muscle is the next safest muscle to use in a newborn but is not the safest.
Option D: Because of the proximity of the sciatic nerve, the gluteus maximus muscle should not be until the child has been walking 2 years.