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A nurse is assessing a preterm newborn who is at 32 weeks of gestation. Which of the following finding should the nurse expect?
- A. Minimal arm recoil
- B. Popliteal angle of less than 90
- C. Creases over the entire sole
- D. Sparse lanugo
Correct Answer: B
Rationale: A preterm newborn at 32 weeks of gestation is usually characterized by hip flexion posturing and a popliteal angle of less than 90 degrees. The popliteal angle is the angle at the back of the knee joint when the leg is flexed, and a value of less than 90 degrees is commonly seen in preterm newborns due to their muscle tone immaturity. This finding is consistent with the developmental stage of a preterm infant at 32 weeks gestation.
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A nurse is caring for a client who is receiving oxytocin to augment labor. The client has an intrauterine pressure catheter and an internal fetal scalp electrode for monitoring. Which of the following is an indication that the nurse should discontinue the infusion?
- A. Contraction frequency every 3 min
- B. Contraction duration of 100 seconds
- C. Fetal heart rate with moderate
- D. variability Fetal heart rate of 118/min
Correct Answer: B
Rationale: Prolonged contractions lasting more than 90-120 seconds may reduce placental perfusion and oxygenation to the fetus, leading to fetal distress. This can result in fetal hypoxia and compromise. Therefore, if the contraction duration reaches 100 seconds, it is an indication for the nurse to discontinue the oxytocin infusion to prevent harm to the fetus. Monitoring for appropriate contraction duration is crucial to ensure the well-being of both the mother and the fetus during labor. While contraction frequency every 3 minutes, a fetal heart rate with moderate variability, and a fetal heart rate of 118/min can be normal findings during labor, a prolonged contraction duration is a concerning sign that requires immediate intervention.
What history would lead you to suspect an ectopic pregnancy in a client at 8 weeks' gestation presenting with abdominal pain and bleeding?
- A. Treated one year ago for PID
- B. Irregular cycle for 1 year
- C. Oral contraception for 3 years
- D. Urinary frequency for 1 week
Correct Answer: A
Rationale: A history of previous pelvic inflammatory disease (PID) treatment would lead to suspicion of an ectopic pregnancy in a client presenting with abdominal pain and bleeding at 8 weeks' gestation. PID can cause scarring and damage to the fallopian tubes, increasing the risk of an ectopic pregnancy where the fertilized egg implants outside of the uterus, usually in the fallopian tubes. Symptoms of an ectopic pregnancy can include abdominal pain, vaginal bleeding, and signs of shock, making it important to consider this possibility in a client with a history of PID.
A parent asks the nurse what makes the opening between the baby's atrium close at birth? The nurse's response is that cardiovascular changes that cause to foramen ovale to close at birth are the direct result of:
- A. Increased pressure in the L atrium (with the increase in the blood flow to the L atrium from the lungs, the pressure is
- C. Increased pressure in the R atrium
- D. Changes in the hepatic blood flow
Correct Answer: C
Rationale: The foramen ovale is a normal fetal structure that allows blood to bypass the lungs by shunting blood from the right atrium to the left atrium. This is essential during fetal development since the lungs are not functioning until birth. After birth, when the baby takes its first breaths and the lungs start working, the pressure in the left atrium increases due to the increased blood flow from the pulmonary circulation. This increased pressure in the left atrium causes the foramen ovale to close, preventing blood from flowing from the right atrium to the left atrium. Therefore, the closure of the foramen ovale is a result of the increased pressure in the left atrium rather than any other cardiovascular changes.
The nurse received end of shift report in a high-risk maternity unit. Which patient should the nurse see first?
- A. 26 weeks with placenta previa experiencing blood on toilet tissue after bowel movement (placenta is getting lower)
- B. 30 weeks' gestation with placenta previa whose fetal monitor shows late decelerations
- C. 35 weeks' gestation with grade I abruptio placenta in labor who has strong urge to push
- D. 37 weeks' gestation with pregnancy induced hypertension whose membrane ruptured spontaneously
Correct Answer: C
Rationale: The patient who should be seen first is the 35 weeks' gestation with grade I abruptio placenta in labor who has a strong urge to push. Abruptio placenta is a serious condition where the placenta detaches from the uterine wall before delivery, leading to significant bleeding and potential compromise to both the mother and baby. The strong urge to push indicates that the baby is in distress and immediate intervention is required to prevent potential harm. This patient needs urgent assessment and intervention to ensure the safety of both the mother and the baby.
A pregnant client reports frequent urination and lower abdominal pressure at 36 weeks. What should the nurse explain?
- A. This is a sign of preterm labor.
- B. This indicates urinary tract infection.
- C. This is common due to fetal descent.
- D. This is caused by Braxton Hicks contractions.
Correct Answer: C
Rationale: As the fetus descends into the pelvis (lightening), increased pressure on the bladder causes frequent urination.