A nurse is instructing a female client on how to check her basal body temperature to determine if she is ovulating. The nurse should instruct the client to check her temperature at which of the following times?

1 hour following intercourse

Every morning before arising

Before going to bed every night

On days 13 to 17 of her menstrual cycle

Answer and Explanation

The Correct Answer is B

Choice A reason:
Checking basal body temperature 1 hour following intercourse is not recommended as a method to determine ovulation. Intercourse and physical activity can increase body temperature, which may lead to inaccurate readings. Basal body temperature should be measured after a period of rest, not after physical activity.

Choice B reason:
The basal body temperature method involves measuring the body's at-rest temperature to identify slight changes that occur around the time of ovulation. It is most accurate when taken every morning before getting out of bed, after at least 3 hours of uninterrupted sleep, and before any physical activity, including eating or drinking. A slight increase in basal body temperature typically occurs after ovulation and remains elevated until the next menstrual period. This method requires consistency and precise timing to be effective.

Choice C reason:
Measuring basal body temperature before going to bed every night is not an effective way to track ovulation. The body's temperature fluctuates throughout the day due to various factors, including activity levels, meals, and external temperatures. Therefore, nighttime measurements would not provide the consistent, resting temperature needed to accurately detect ovulation.

Choice D reason:
While it is true that ovulation typically occurs around the middle of the menstrual cycle, which for many women is between days 13 to 17, limiting temperature checks to these days only may miss the initial rise in temperature that indicates ovulation. Ovulation can vary from cycle to cycle, and it is important to measure basal body temperature daily to detect the pattern over time.

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Correct Answer is B

Explanation

Choice A reason:
Covering the cord with a sterile, moist saline dressing can help to maintain the cord's viability by preventing drying and possible infection. However, this action does not address the immediate concern of relieving pressure on the cord to restore fetal circulation.

Choice B reason:
Placing the client in the knee-chest position is the most immediate and critical action to take. This position helps to relieve pressure on the prolapsed cord, which is vital to prevent compression of the cord and maintain blood flow to the fetus. It is a recommended emergency intervention for umbilical cord prolapse.

Choice C reason:
Inserting a gloved hand into the vagina to relieve pressure on the cord is a measure that may be taken by a healthcare provider in the event of a cord prolapse. However, it is not the first action to be performed. The initial step is to change the mother's position to relieve pressure on the cord.

Choice D reason:
Preparing the client for an immediate birth is necessary because umbilical cord prolapse is an obstetric emergency that requires prompt delivery, often by cesarean section, to prevent fetal hypoxia. However, the very first action is to relieve pressure on the cord to restore fetal oxygenation while preparations for delivery are made.

A. Blood pressure 148/98 mm Hg B. 3+ protein in the urine C. 1+ pitting sacral edema D. Deep tendon reflexes of +1

Correct Answer is D

Explanation

Choice A reason:
A blood pressure reading of 148/98 mm Hg is consistent with preeclampsia. High blood pressure is a hallmark sign of preeclampsia, and a reading at or above 140/90 mm Hg is considered elevated and may warrant a preeclampsia diagnosis.

Choice B reason:
The presence of 3+ protein in the urine is another indicator consistent with preeclampsia. Proteinuria, or high levels of protein in the urine, is a common symptom of preeclampsia and can indicate kidney involvement.

Choice C reason:
1+ pitting sacral edema is also consistent with preeclampsia. While some swelling is normal during pregnancy, sudden or excessive swelling (edema) can be a sign of preeclampsia, especially when it occurs in the face, hands, or around the eyes.

Choice D reason:
Deep tendon reflexes of +1 are generally considered to be within the normal range. In preeclampsia, hyperreflexia, or increased reflexes, are more common due to heightened nervous system activity, which would be indicated by a score higher than +2². Therefore, a finding of +1 is inconsistent with preeclampsia and may suggest that reflexes are not as heightened as would typically be expected in this condition.

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A nurse is instructing a female client on how to check her basal body temperature to determine if she is ovulating. The nurse should instruct the client to check her temperature at which of the following times?

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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