Custom: NSG 135 Exam #3 Spring 2025

Explanation

D. Changes in the cervix
One of the key signs of true labor is cervical changes. In true labor, the cervix begins to efface (thin out) and dilate (open) in preparation for delivery. These changes are monitored by a healthcare provider during a vaginal exam and indicate that labor is progressing. In contrast, false labor (Braxton Hicks contractions) may cause irregular contractions, but they do not result in cervical changes.

Why the Other Options Are Incorrect:

A. Station of the presenting part
The station of the presenting part refers to the position of the fetus in the birth canal in relation to the ischial spines. While it is important in assessing labor progression, station alone does not confirm whether the client is in true labor. It is more of an indicator of the fetal descent during labor.

B. Pattern of contractions
Although contractions in true labor are typically regular and increase in intensity and frequency, the pattern of contractions alone is not a definitive sign of true labor. It is the cervical changes that provide the most reliable evidence of labor progression.

C. Rupture of the membranes
Rupture of membranes (also known as the water breaking) is a sign that labor may be imminent, but it does not necessarily confirm that a woman is in true labor. Some women may have ruptured membranes without contractions, and labor may not follow immediately. Additionally, rupture of membranes can occur in both true and false labor.

Summary:

The correct answer is D. Changes in the cervix. Cervical changes (effacement and dilation) are the most reliable sign of true labor, indicating that labor is progressing. The other options may be associated with labor but are not definitive signs of true labor on their own.

Explanation

D. Rubella
Rubella, also known as German measles, is part of the TORCH infections (Toxoplasmosis, Other, Rubella, Cytomegalovirus, Herpes simplex virus). Rubella infection during pregnancy, especially in the first trimester, can cause serious congenital abnormalities in the fetus, including congenital heart defects, cataracts, hearing loss, and intellectual disabilities. This is why rubella immunization is highly recommended before pregnancy.

Why the Other Options Are Incorrect:

A. Malaria
While malaria can cause complications in pregnancy such as preterm labor and low birth weight, it is not considered part of the TORCH group. It is not typically associated with congenital abnormalities caused directly by infection.

B. Trichomoniasis
Trichomoniasis is a sexually transmitted infection that can cause preterm birth or low birth weight, but it is not part of the TORCH group and does not usually lead to congenital abnormalities in the fetus.

C. HIV
While HIV can be transmitted to the fetus during pregnancy, labor, or breastfeeding, it does not typically cause congenital abnormalities. It is more likely to result in HIV infection in the newborn, which can be managed with antiretroviral therapy.

Summary:

The correct answer is D. Rubella, as it is a TORCH infection that can cause congenital abnormalities in the fetus, especially if contracted during the early stages of pregnancy. The other infections, while serious, are not typically associated with congenital abnormalities caused directly by the infection.

Explanation

Correct answer: A. "This medication promotes softening of the cervix."

Explanation:

• A. "This medication promotes softening of the cervix":
  
  • Dinoprostone gel is a prostaglandin used to ripen the cervix in preparation for labor. It helps in softening, dilating, and effacing the cervix to facilitate labor. This is the correct purpose of dinoprostone in prenatal care.
    

Why the other options are incorrect:

• B. "This medication is used to treat preeclampsia":
  
  • Dinoprostone is not used to treat preeclampsia. Preeclampsia is typically managed with antihypertensive medications, magnesium sulfate, and possibly delivery. Dinoprostone is used for cervical ripening and induction of labor, not for preeclampsia.
    
• C. "It causes relaxation of the uterine muscles":
  
  • Dinoprostone does not primarily cause relaxation of the uterine muscles. It is used to promote cervical ripening and initiate labor, but it does not relax the uterine muscles. Medications like tocolytics (e.g., terbutaline) are used to relax the uterine muscles in preterm labor.
    
• D. "It is used to treat genital herpes simplex virus":
  
  • Dinoprostone is not used to treat genital herpes simplex virus. The treatment for genital herpes typically involves antiviral medications (e.g., acyclovir), not cervical ripening agents like dinoprostone.
    

Correct Answer Is:

Dinoprostone gel is used to soften the cervix and promote cervical changes to help initiate labor. It does not treat preeclampsia, herpes, or cause uterine muscle relaxation.

Explanation

C. Insulin
When gestational diabetes mellitus (GDM) cannot be controlled with diet, exercise, and oral hypoglycemic medications, insulin is typically prescribed as the next step. Insulin is the most commonly used medication to manage gestational diabetes, as it does not cross the placenta and is considered safe for both the mother and fetus. It helps regulate blood glucose levels in women who are unable to achieve adequate control with non-insulin therapies.

Why the Other Options Are Incorrect:

A. Letrozole
Letrozole is a medication used to treat hormone receptor-positive breast cancer and can also be used for ovulation induction in women with infertility. It is not used for gestational diabetes mellitus and would be inappropriate in this situation.

B. Lactulose
Lactulose is a medication used to treat constipation and hepatic encephalopathy. It has no role in managing gestational diabetes mellitus and is not indicated for this client.

D. Metoprolol
Metoprolol is a beta-blocker used to treat conditions like hypertension, angina, and heart failure. It is not used to treat gestational diabetes mellitus and would not be appropriate for this client.

Summary:

The correct answer is C. Insulin. Insulin is the standard treatment for gestational diabetes when diet, exercise, and oral medications are insufficient to control blood glucose levels. The other options are not appropriate for managing gestational diabetes.

Explanation

The correct answers are:

• B. Swaddle the newborn.
  
• C. Administer oral morphine.
  
• E. Continue NAS scoring as prescribed.
  

Explanation for the correct answers:

• B. Swaddle the newborn:
  
  • Swaddling the newborn is a common intervention for infants with Neonatal Abstinence Syndrome (NAS). It helps provide comfort and security, and can also reduce excessive movement that might be related to the newborn's hyperactivity or tremors. Swaddling also assists in maintaining body temperature, which is important for this infant as they may have difficulty regulating temperature due to NAS symptoms.
    
• C. Administer oral morphine:
  
  • Oral morphine is a common treatment for Neonatal Abstinence Syndrome (NAS) to help manage symptoms of withdrawal in infants exposed to opioids like heroin during pregnancy. The NAS score of 20 indicates moderate to severe withdrawal symptoms, and oral morphine may be prescribed to help alleviate symptoms such as excessive crying, tremors, poor feeding, and irritability. The treatment is usually given in a tapering dose to gradually wean the infant off opioids.
    
• E. Continue NAS scoring as prescribed:
  
  • The NAS scoring is essential to assess the severity of the newborn's withdrawal symptoms and to guide treatment decisions. The nurse should continue to monitor the newborn's condition regularly using the NAS tool to track any changes and adjust interventions as needed. This ensures appropriate management of the infant's symptoms and progress.
    

Why the other options are incorrect:

• A. Encourage the birthing parent to breastfeed:
  
  • Breastfeeding is generally recommended for most newborns as it provides vital nutrients and immunological support. However, in cases of NAS, breastfeeding may not always be recommended, especially if the mother is actively using substances like heroin or other opioids. In these cases, breastfeeding may pose a risk of the infant receiving substances through breast milk. The nurse should first assess whether the mother is sober and whether breastfeeding is safe in this specific case. The provider will typically provide guidance on this matter.
    
• D. Administer naloxone for NAS scores greater than 24:
  
  • Naloxone is a medication used to reverse opioid overdose, but it is not used to treat NAS directly. Administering naloxone to a newborn with NAS can lead to precipitated withdrawal, which can worsen the symptoms. Naloxone is typically not indicated for NAS management, as its primary purpose is to treat opioid toxicity or overdose, not withdrawal. For NAS, morphine or methadone are typically used to manage symptoms.
    

Correct Answer Is:

The nurse should anticipate interventions such as swaddling to comfort the newborn, administering oral morphine for withdrawal management, and continuing to monitor the newborn's condition through NAS scoring. These actions are critical for providing appropriate care for a newborn experiencing opioid withdrawal symptoms due to heroin exposure in utero.

Explanation

The correct answer is:

A. It prevents the formation of Rh antibodies in mothers who are Rh negative.

Explanation for the correct answer:

• Rh(D) immunoglobulin is administered to Rh-negative mothers to prevent the formation of Rh antibodies. When an Rh-negative mother carries an Rh-positive baby, there is a risk of her immune system producing antibodies against Rh-positive blood cells (a process called sensitization). The Rh(D) immunoglobulin prevents the mother's immune system from producing these antibodies, thus protecting future pregnancies from Rh incompatibility.
  

Why the other options are incorrect:

• B. It destroys Rh antibodies in mothers who are Rh negative.
  
  • This is incorrect. Rh(D) immunoglobulin does not destroy antibodies but prevents the formation of Rh antibodies. If antibodies have already been formed, the immunoglobulin is not effective.
    
• C. It prevents the formation of Rh antibodies in newborns who are Rh positive.
  
  • This is incorrect. The Rh(D) immunoglobulin is administered to the mother, not the newborn, to prevent the formation of antibodies in the mother. It does not affect the newborn's immune system directly.
    
• D. It destroys Rh antibodies in newborns who are Rh positive.
  
  • This is incorrect. Rh(D) immunoglobulin is not intended to destroy antibodies in newborns. It is administered to the mother to prevent the development of antibodies that could affect future pregnancies, not to treat the newborn.
    

Correct Answer Is:

Rh(D) immunoglobulin is given to Rh-negative mothers to prevent the formation of Rh antibodies in the mother, which helps prevent complications in future pregnancies with Rh-positive infants.

Explanation

The correct answer is:

C. Access to prenatal care

Explanation for the correct answer:

• Access to prenatal care is the most significant factor influencing maternal health outcomes in the United States. Regular prenatal care helps identify and manage complications early in pregnancy, provides essential screenings and tests, and promotes healthy behaviors and lifestyle changes. Lack of access to prenatal care increases the risk of complications such as preterm labor, preeclampsia, gestational diabetes, and poor fetal outcomes. It is essential to ensure that pregnant women have access to the necessary medical care to ensure the health of both the mother and the baby.
  

Why the other options are incorrect:

• A. Occupation
  
  • While occupation can impact health, especially in cases where the job exposes the individual to harmful substances or physical stress, it does not have as significant an impact on maternal health outcomes as access to prenatal care.
    
• B. Level of education
  
  • Education level can influence health outcomes, but it is less directly impactful compared to access to prenatal care. Education often affects health literacy and decision-making, but prenatal care is a more direct intervention for improving maternal health.
    
• D. Marital status
  
  • Marital status may affect maternal health outcomes in some ways (e.g., emotional support), but it is not as directly influential as having access to prenatal care. Many other factors, such as socioeconomic status and access to healthcare, play a larger role in maternal health.
    

Correct Answer Is:

Access to prenatal care is the most significant factor influencing maternal health outcomes in the United States, as it directly impacts the ability to monitor and address health issues during pregnancy. While other factors like occupation, education, and marital status can influence health, they do not have as profound an effect on maternal health outcomes as prenatal care.

Explanation

Explanation for the Correct Answers:

A. Provide a dark, quiet environment
Clients with severe gestational hypertension or severe preeclampsia may be at risk for seizures, so a dark, quiet environment helps to reduce stimuli and decrease the risk of neurologic irritability and seizures.

C. Administer magnesium sulfate IV
Magnesium sulfate is given to clients with severe gestational hypertension to prevent seizures. It helps to manage neurologic irritability and can be lifesaving for seizure prophylaxis.

D. Ensure that calcium gluconate is readily available
Calcium gluconate is the antidote for magnesium sulfate toxicity, which can cause respiratory depression and cardiac issues. It is critical to have it readily available in case of an overdose.

Why the Other Options Are Incorrect:

B. Assess respiratory status every 4 hr
Respiratory status should be assessed more frequently (typically every 1–2 hours) when the client is on magnesium sulfate, as magnesium sulfate toxicity can lead to respiratory depression. Every 4 hours is insufficient.

E. Evaluate neurologic status every 8 hr
Neurologic status should be evaluated more frequently (typically every hour or every 2 hours) for early signs of eclampsia or magnesium sulfate toxicity, not just every 8 hours.

Summary:

The correct answers are A. Provide a dark, quiet environment, C. Administer magnesium sulfate IV, and D. Ensure that calcium gluconate is readily available. These actions help manage severe gestational hypertension and prevent seizures. Frequent assessment of respiratory and neurologic status is necessary, so every 4 hours or every 8 hours is not adequate.

Explanation

The correct answer is:

B. Slightly above the umbilicus

Explanation for the correct answer:

• Fundal height is a useful indicator of fetal growth and development during pregnancy. At 22 weeks of gestation, the fundus is typically located slightly above the umbilicus. The general rule is that the fundal height, in centimeters, corresponds approximately to the gestational age in weeks, give or take 2 cm. Therefore, at 22 weeks, the fundus is expected to be around 22 cm from the pubic symphysis, which typically places it slightly above the umbilicus.
  

Why the other options are incorrect:

• A. Slightly below the umbilicus:
  
  • At 22 weeks of gestation, the fundus should not be located below the umbilicus. It would typically be higher, closer to the umbilicus or slightly above it, depending on the individual client.
    
• C. 3 cm below the umbilicus:
  
  • This is not accurate for a 22-week pregnancy. At this stage, the fundus would be at or just above the level of the umbilicus, not below it.
    
• D. 3 cm above the umbilicus:
  
  • While it’s possible for the fundus to be slightly above the umbilicus at 22 weeks, a measurement of 3 cm above would be more typical at a later gestational age, closer to 24–26 weeks. At 22 weeks, the fundus would typically be just slightly above the umbilicus, not 3 cm.
    

Correct Answer Is:

At 22 weeks of gestation, the fundus should be palpated slightly above the umbilicus, which is consistent with the general rule that fundal height should be approximately equal to the gestational age in weeks.