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A nurse is assessing a client who is in active labor. Which of the following findings should the nurse report to the provider?
- A. Contractions lasting 80 seconds.
- B. Early decelerations in the PHR.
- C. Temperature 37.4° C (99 3* F).
- D. PHR baseline 170/min.
Correct Answer: D
Rationale: The correct answer is D: PHR baseline 170/min. A baseline fetal heart rate (FHR) of 170/min is considered tachycardia in labor, which may indicate fetal distress. The nurse should report this finding to the provider promptly for further evaluation and intervention. Contractions lasting 80 seconds (choice A) are within the normal range. Early decelerations (choice B) are typically benign and do not require immediate intervention. A temperature of 37.4° C (choice C) is slightly elevated but not a critical finding in active labor. Therefore, choice D is the most concerning and requires immediate attention.
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Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing. 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
- A. Place newborn skin to skin on birthing parents chest, Encourage birthing parents to breastfeed, Obtain prescription for arterial blood gases, Plan to initiate phototherapy, Perform neonatal abstinence system scoring
- B. Cold stress, Acute bilirubin encephalopathy, Respiratory distress syndrome, Neonatal abstinence syndrome (NAS)
- C. Stool output, Temperature, Lung sounds, Blood glucose level, Bilirubin level
Correct Answer:
Rationale: Action to Take: A, B; Potential Condition: B; Parameter to Monitor: C, E.
Rationale:
The correct answer is to place the newborn skin to skin on the birthing parent's chest and encourage breastfeeding to address Cold stress, a potential condition the client is most likely experiencing. These actions help regulate the newborn's temperature and provide essential warmth and nutrition. Parameters to monitor would include temperature (to assess for hypothermia) and bilirubin level (to monitor for jaundice, a common issue in newborns). Monitoring these parameters will help the nurse assess the client's progress and ensure appropriate interventions are implemented.
A nurse is caring for a client who has preeclampsia and is receiving a continuous infusion of magnesium sulfate IV. Which of the following actions should the nurse take?
- A. Restrict hourly fluid intake to 150 mL/hr.
- B. Have calcium gluconate readily available.
- C. Assess deep tendon reflexes every 6 hr.
- D. Monitor intake and output every 4 hr.
Correct Answer: B
Rationale: The correct answer is B: Have calcium gluconate readily available. Magnesium sulfate IV can cause toxicity leading to respiratory depression and cardiac arrest. Calcium gluconate is the antidote for magnesium sulfate toxicity as it antagonizes the effects of magnesium on the muscles. Having it readily available ensures prompt treatment in case of toxicity.
Restricting fluid intake (A) is not necessary for preeclampsia and can lead to dehydration. Assessing deep tendon reflexes (C) every 6 hours is important but not as crucial as having the antidote readily available. Monitoring intake and output (D) every 4 hours is important for overall assessment but does not directly address magnesium sulfate toxicity.
A nurse is reviewing the medical record of a newly admitted client who is at 32 weeks of gestation. Which of the following conditions is an indication for fetal assessment using electronic fetal monitoring?
- A. Oligohydramnios.
- B. Hyperemesis gravidarum.
- C. Leukorrhea.
- D. Periodic tingling of the fingers.
Correct Answer: A
Rationale: The correct answer is A: Oligohydramnios. Electronic fetal monitoring is indicated for assessing fetal well-being in pregnancies with conditions that may compromise fetal oxygenation, such as oligohydramnios. Oligohydramnios is a condition where there is an insufficient amount of amniotic fluid around the fetus, which can lead to fetal distress. Electronic fetal monitoring helps track the fetal heart rate and uterine contractions to detect signs of distress. Hyperemesis gravidarum (B), leukorrhea (C), and periodic tingling of the fingers (D) are not indications for fetal monitoring as they do not directly impact fetal well-being.
A nurse is assessing the newborn of a client who took a selective serotonin reuptake inhibitor (SSRI) during pregnancy. Which of the following manifestations should the nurse identify as an indication of withdrawal from an SSRI?
- A. Large for gestational age
- B. Hyperglycemia
- C. Bradypnea
- D. Vomiting
Correct Answer: D
Rationale: The correct answer is D: Vomiting. Newborns exposed to SSRIs in utero may experience withdrawal symptoms due to drug discontinuation at birth. Vomiting is a common withdrawal manifestation in newborns due to the sudden absence of the drug. Large for gestational age (choice A) is not typically associated with SSRI withdrawal. Hyperglycemia (choice B) and bradypnea (choice C) are not typical withdrawal symptoms of SSRIs. Therefore, the nurse should identify vomiting as an indication of withdrawal from an SSRI in the newborn.
For each assessment finding, click to specify if the finding is consistent with hypoglycemia, hyperbilirubinemia, or sepsis.
- A. Ecchymotic caput Succedaneum.
- B. Decreased temperature.
- C. Lethargy.
- D. Poor feeding.
- E. Respiratory distress.
- F. Yellow sclera and oral mucosa.
Correct Answer: B, C, D, E, F
Rationale: The correct answer is because decreased temperature (B), lethargy (C), poor feeding (D), respiratory distress (E), and yellow sclera and oral mucosa (F) are consistent with hypoglycemia, hyperbilirubinemia, and sepsis. Decreased temperature can indicate hypoglycemia, lethargy and poor feeding can be seen in hypoglycemia and sepsis, respiratory distress can be a sign of sepsis, and yellow sclera and oral mucosa can be indicative of hyperbilirubinemia. Ecchymotic caput succedaneum is more related to birth trauma and is not specific to these conditions.