Nokea
The client in labor tells the nurse that it feels like her membranes just ruptured. Which assessment finding of the amniotic fluid would indicate that it is normal?
- A. Cloudy in color
- B. Has a strong odor
- C. Meconium stained
- D. Has a pH of 7.1
Correct Answer: D
Rationale: The pH of amniotic fluid is usually between 6.5 and 7.5, which is more alkaline than urine or purulent material. Normal amniotic fluid should be clear. Cloudiness could indicate the presence of meconium or an intrauterine infection. Amniotic fluid should have no odor. Any odor may indicate the presence of infection. Amniotic fluid should be clear. Meconium stained could indicate fetal distress.
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The nurse advises the client that this test is typically performed at what time during the pregnancy?
- A. Just after the pregnancy is confirmed
- B. Early in the second trimester
- C. In the transition phase of labor
- D. Just after the first fetal movements
Correct Answer: B
Rationale: Amniocentesis is typically performed early in the second trimester (15-20 weeks) to assess for genetic abnormalities.
The client is hospitalized at 30 weeks’ gestation in preterm labor. A test is performed to determine the lecithin to sphingomyelin (L/S) ratio, with results indicating a ratio less than 2:1. The nurse planning care for the client should expect to implement which interventions? Select all that apply.
- A. Administering hydralazine
- B. Maintaining the client on bedrest
- C. Preparing the client for a nonstress test
- D. Giving betamethasone
- E. Administering metronidazole
Correct Answer: B,C,D
Rationale: Bed rest will maximize placental oxygenation while fetal lung maturity continues. The client should be prepared for a nonstress test. This is used to monitor for uterine contractions and labor. Labor needs to be stopped until the fetal lungs are more fully developed. Betamethasone (Celestone Soluspan) is a corticosteroid and is given to stimulate fetal lung maturity. Hydralazine (Apresoline) is an antihypertensive agent and is administered to clients experiencing preeclampsia, not preterm labor. Metronidazole (Flagyl) is an antiprotozoal and antibacterial agent used to treat a vaginal infection; there is no indication that the client has a vaginal infection.
The nurse advises the client to practice which technique to cope with labor pain?
- A. Lamaze breathing
- B. Holding her breath
- C. Tensing muscles
- D. Avoiding movement
Correct Answer: A
Rationale: Lamaze breathing helps manage labor pain by promoting relaxation and focus, unlike tensing or breath-holding.
The nurse is caring for the client who just gave birth. Which observation of the client should lead the nurse to be concerned about the client’s attachment to her male infant?
- A. Asking the caregiver about how to change his diaper
- B. Comparing her newborn’s nose to her brother’s nose
- C. Calling the baby “Kelly,” which was the name selected
- D. Repeatedly telling her husband that she wanted a girl
Correct Answer: D
Rationale: Seeking information about infant care is a sign that the mother is developing attachment to her infant. Pointing out family traits or characteristics seen in the newborn is a sign that the mother is developing attachment. Calling the infant by name is a sign that the mother is developing attachment to her infant. Attachment is demonstrated by expressing satisfaction with a baby’s appearance and sex. Frequent expressions of dissatisfaction with the sex of the infant should be concerning and followed up.
Which client would the nurse identify as being at highest risk for developing complications during pregnancy?
- A. A 17-year-old gravida I client
- B. A client with the placenta implanted on the fundus of the uterus
- C. A client who has nausea and vomiting during the first trimester
- D. A 35-year-old gravida V client
Correct Answer: D
Rationale: A 35-year-old gravida V client is at higher risk due to advanced maternal age and multiple pregnancies, increasing complication risks.