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The nurse is assessing a client in labor and notes persistent late decelerations on the monitor. What is the priority action?
- A. Reposition the client to her left side.
- B. Administer oxygen via face mask.
- C. Increase IV fluids.
- D. Notify the healthcare provider.
Correct Answer: A
Rationale: The correct answer is A: Reposition the client to her left side. This is the priority action because late decelerations indicate uteroplacental insufficiency, possibly due to compression of the umbilical cord. Repositioning the client to her left side can help improve blood flow to the placenta by reducing pressure on the vena cava, thus optimizing fetal oxygenation. Administering oxygen (B) is important but not the immediate priority. Increasing IV fluids (C) may not directly address the cause of late decelerations. Notifying the healthcare provider (D) is important but should come after immediate interventions.
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A client at 20 weeks' gestation asks about fetal movements. What is the nurse's best response?
- A. Fetal movements are rarely felt before 24 weeks.
- B. You should feel strong, regular movements at this stage.
- C. You may feel fluttering movements, known as quickening.
- D. It is too early to feel any fetal movements.
Correct Answer: C
Rationale: The correct answer is C because quickening, described as fluttering movements, is typically felt by pregnant individuals around 18-20 weeks of gestation. This indicates fetal movement and is an important milestone in pregnancy. Choices A and D are incorrect as fetal movements can be felt as early as 18-20 weeks. Choice B is incorrect as feeling strong, regular movements is not expected until later in the pregnancy.
Which assessment finding suggests that the laboring client's
- B. Reflex grade 0
- C. Urine output 60
- D. Generalized seizure
Correct Answer: D
Rationale: The correct answer is D, Generalized seizure. During labor, a generalized seizure is a critical finding that indicates eclampsia, a severe complication of pregnancy characterized by seizures, hypertension, and proteinuria. This requires immediate medical intervention to prevent harm to the mother and baby. Reflex grade 0 (choice B) is not a typical assessment finding during labor, and it does not indicate any immediate life-threatening condition. Urine output of 60 (choice C) is within the normal range and does not suggest any immediate critical issue. Therefore, choice D is the correct answer due to the urgency and severity of the condition it represents.
Which finding in a laboring mother requires immediate intervention?
- A. Contractions occurring every 5 minutes
- B. Late decelerations on fetal heart monitor
- C. Early decelerations on fetal heart monitor
- D. Elevated maternal temperature during labor
Correct Answer: D
Rationale: The correct answer is D: Elevated maternal temperature during labor. This finding indicates a potential infection, such as chorioamnionitis, which can be harmful to both the mother and the baby if not promptly treated. Immediate intervention is necessary to prevent complications like sepsis.
Contractions every 5 minutes (A) are within the normal range for active labor. Late decelerations (B) can indicate uteroplacental insufficiency and require monitoring but not immediate intervention unless persistent. Early decelerations (C) are usually benign and do not typically require immediate action.
A client at 20 weeks' gestation reports leg cramps. What recommendation should the nurse provide?
- A. Increase potassium intake.
- B. Stretch the legs before bed.
- C. Drink fluids during meals.
- D. Reduce physical activity.
Correct Answer: B
Rationale: The correct answer is B: Stretch the legs before bed. Leg cramps during pregnancy are common due to increased weight and pressure on blood vessels. Stretching before bed helps prevent cramps by improving circulation and muscle relaxation. Increasing potassium intake (choice A) can help with muscle function but is not the primary intervention for leg cramps. Drinking fluids during meals (choice C) is important for hydration but does not directly address leg cramps. Reducing physical activity (choice D) may worsen circulation and muscle cramps.
How can a nurse best prevent heat loss in a newborn during the first hour of life?
- A. Place the newborn under a radiant warmer
- B. Dry the newborn and cover with a warm blanket
- C. Place the newborn in a skin-to-skin position with the mother
- D. Keep the newborn wrapped in a wet blanket
Correct Answer: A
Rationale: The correct answer is A: Place the newborn under a radiant warmer. This method is the most effective in preventing heat loss in a newborn as radiant warmers provide a consistent heat source to maintain the newborn's body temperature. This is crucial during the first hour of life when newborns are at a higher risk of hypothermia.
Choice B is not as effective as using a radiant warmer as it may not provide enough warmth to prevent heat loss. Choice C, placing the newborn in a skin-to-skin position with the mother, is beneficial for bonding and regulating the newborn's temperature in the long term but may not be as effective as a radiant warmer in the immediate post-birth period.
Choice D, keeping the newborn wrapped in a wet blanket, is incorrect as wet blankets can further contribute to heat loss through evaporative cooling. In summary, using a radiant warmer is the best option for preventing heat loss in a newborn during the critical first hour of life.