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A nurse is caring for a client who is to receive oxytocin to augment their labor. Which of the following findings contraindicates the initiation of the oxytocin infusion and should be reported to the provider?
- A. Late decelerations.
- B. Moderate variability of the FHR.
- C. Cessation of uterine dilation.
- D. Prolonged active phase of labor.
Correct Answer: A
Rationale: Late decelerations in the fetal heart rate are a sign of fetal distress and contraindicate the use of oxytocin, as it can exacerbate the distress.
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A nurse is calculating the estimated date of delivery for a client who reports that the first day of her last menstrual period was August 10. Using Nägele’s Rule, which of the following is the client’s estimated date of delivery?
- A. May 13
- B. May 17
- C. May 3
- D. May 20
Correct Answer: B
Rationale: The correct answer is B: May 17. Nägele's Rule calculates the estimated date of delivery by adding 7 days to the first day of the last menstrual period, then subtracting 3 months, and finally adding 1 year. In this case, August 10 + 7 days = August 17. Subtracting 3 months gives us May 17, which is the estimated date of delivery. Choice A (May 13) is too early as it doesn't account for the full gestational period. Choice C (May 3) is also too early, and choice D (May 20) is too late based on the calculation.
A nurse is assessing a newborn who was born at 26 weeks of gestation using the New Ballard Score. Which of the following findings should the nurse expect?
- A. Minimal arm recoil
- B. Popliteal angle of 90°
- C. Creases over the entire foot sole
- D. Raised areolas with 3 to 4 mm buds
Correct Answer: A
Rationale: The correct answer is A: Minimal arm recoil. In premature newborns, the lack of muscle tone results in minimal arm recoil, which is a characteristic finding in the New Ballard Score for assessing gestational age. This is due to the immaturity of the neuromuscular system in premature infants. Choice B, popliteal angle of 90°, is incorrect as flexion of the hips and knees is more common in preterm infants. Choice C, creases over the entire foot sole, is incorrect as full development of foot sole creases is seen in term infants. Choice D, raised areolas with 3 to 4 mm buds, is incorrect as these are signs of breast development and are not specific to gestational age assessment.
A nurse is assessing a client who is 3 days postpartum. Which of the following findings should the nurse report to the provider?
- A. Cool, clammy skin
- B. Moderate lochia serosa
- C. Heart rate 89/min
- D. BP 120/70 mm Hg
Correct Answer: A
Rationale: The correct answer is A: Cool, clammy skin. This finding could indicate hypovolemic shock, a serious complication postpartum. The nurse should report this to the provider immediately for further assessment and intervention. Choice B, moderate lochia serosa, is a normal finding 3 days postpartum. Choice C, heart rate 89/min, and choice D, BP 120/70 mm Hg, are within normal limits for a postpartum client and do not require immediate reporting.
A nurse is planning care for a toddler who has epiglottitis. which of the following interventions should the nurse include.
- A. Offer a high-calorie, high-protein diet.
- B. Administer pancreatic enzymes with meals.
- C. Initiate droplet precautions.
- D. Carefully suction the child's oropharynx to remove secretions
Correct Answer: C
Rationale: Epiglottitis is a medical emergency, and droplet precautions are necessary to prevent the spread of infection. Suctioning the oropharynx can worsen airway obstruction and is not recommended.
A nurse is assessing a newborn who is 16 hr old. Which of the following findings should the nurse report to the provider?
- A. Substernal retractions
- B. Acrocyanosis
- C. Overlapping suture lines
- D. Head circumference 33 cm (13 in)
Correct Answer: A
Rationale: Substernal retractions are a sign of respiratory distress in newborns and require immediate medical attention to ensure proper oxygenation.