A nurse in labor and delivery is caring for a client. Following delivery of the placenta, the nurse examines the umbilical cord. Which of the following vessels should the nurse expect to observe in the umbilical cord?

Two arteries and one vein

Two veins and one artery

One artery and one vein

Two arteries and two veins

Answer and Explanation

The Correct Answer is A

The correct answer is A. Two arteries and one vein.

A. Two arteries and one vein is the typical composition of the umbilical cord vessels. The umbilical arteries carry deoxygenated blood and waste products away from the fetus, while the umbilical vein carries oxygenated blood and nutrients to the fetus.

B. Two veins and one artery is not the usual configuration of the umbilical cord vessels. The presence of two veins is atypical.

C. One artery and one vein is an abnormal finding and may be associated with certain congenital anomalies or fetal abnormalities. This configuration is not the norm.

D. Two arteries and two veins is not a standard or physiological composition of the umbilical cord. The typical configuration is two arteries and one vein.

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Correct Answer is A

Explanation

Choice A Reason:

"You can miss your period for several other reasons. Describe your typical menstrual cycle." This response acknowledges that a missed period can result from various factors other than pregnancy, such as stress, changes in weight, hormonal fluctuations, or certain medical conditions. Understanding the client's typical menstrual cycle can help the nurse gather more information about potential reasons for the late period.

Choice B Reason:

"If you have been sexually active and haven't used protection, it is likely that you are pregnant. “This response assumes pregnancy without exploring other possibilities or the client's individual situation.

Choice C Reason:

"Let's check to see if you have any other signs of pregnancy. Have you noticed any abdominal enlargement yet?" While considering other signs of pregnancy is reasonable, focusing on abdominal enlargement may not be the most accurate early indicator, and it's essential to explore a broader range of symptoms.

Choice D Reason:

"Because you have missed your period, you should try taking a home pregnancy test before you start worrying. "While suggesting a home pregnancy test is reasonable, it may be more beneficial to gather additional information about the client's menstrual cycle and potential symptoms before jumping directly to a test.

A. Assist the client to turn onto her side. B. Assist the client to an upright position. C. Prepare for a cesarean birth D. Prepare for an immediate vaginal delivery.

Correct Answer is A

Explanation

The correct answer is A. Assist the client to turn onto her side.

A. Assisting the client to turn onto her side is the correct intervention. This is because the client's blood pressure is low, and turning onto the side helps improve blood flow to the uterus, reducing the risk of supine hypotension.

B. Assisting the client to an upright position is not the priority in this case. The client is at risk for supine hypotension, and a lateral position is more appropriate.

C. Preparing for a cesarean birth is not indicated based solely on the blood pressure reading. Turning the client onto her side and monitoring the blood pressure response are appropriate initial actions.

D. Preparing for an immediate vaginal delivery is not indicated based solely on the blood pressure reading. The client's condition may improve with positional changes, and further assessment is needed.

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A nurse in labor and delivery is caring for a client. Following delivery of the placenta, the nurse examines the umbilical cord. Which of the following vessels should the nurse expect to observe in the umbilical cord?

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Naxlex Comprehensive Predictor Exams

A nurse in a prenatal clinic is caring for a client who reports that her menstrual period is 2 weeks late. The client appears anxious and asks the nurse if she is pregnant. Which of the following responses should the nurse make?

Correct Answer is A

Explanation

A nurse is caring for a client who is at 40 weeks gestation and is in active labor. The client has 6 cm of cervical dilation and 100% cervical effacement. The nurse obtains the client's blood pressure reading as 82/52 mm Hg. Which of the following nursing interventions should the nurse perform?

Correct Answer is A

Explanation

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