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What is the most critical sign of fetal distress during labor?
- A. Accelerations in fetal heart rate
- B. Decreased variability in fetal heart rate
- C. Early decelerations in fetal heart rate
- D. Late decelerations in fetal heart rate
Correct Answer: D
Rationale: The correct answer is D: Late decelerations in fetal heart rate. Late decelerations indicate uteroplacental insufficiency, where the fetus is not receiving enough oxygen during contractions. This is critical as it can lead to fetal hypoxia and acidosis, posing a risk to the baby's well-being. Early decelerations (C) are generally benign and result from head compression during contractions. Accelerations (A) are a reassuring sign indicating fetal well-being. Decreased variability (B) can be concerning but is not as critical as late decelerations in indicating fetal distress.
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A client in labor with ruptured membranes is diagnosed with chorioamnionitis. What is the priority nursing action?
- A. Administer prescribed antibiotics.
- B. Encourage the client to ambulate.
- C. Increase the oxytocin infusion rate.
- D. Perform a sterile vaginal examination.
Correct Answer: A
Rationale: The correct answer is A: Administer prescribed antibiotics. The priority nursing action in a client with chorioamnionitis is to administer antibiotics promptly to prevent infection spread to the fetus and mother. Antibiotics help treat the infection and reduce complications. Encouraging ambulation (B) may not be safe due to the risk of infection. Increasing oxytocin infusion rate (C) could worsen the infection. Performing a sterile vaginal examination (D) is contraindicated as it can introduce more bacteria. Administering antibiotics is the most urgent and effective intervention in this situation.
A 28-year-old G1 P0 client tells the nurse that she medication cabergoline, which is effective in reducing has a craving for chalk. What is the nurse's best prolactin levels. What are possible side effects of this response to her?
- A. That is not normal for anyone. We need to refer
- B. Hypotension you to a therapist.
- C. Nasal congestion
- D. Tell me more about why you have a craving for it.
Correct Answer: D
Rationale: Step 1: The nurse should engage the client to gather more information about the craving for chalk. This helps in understanding the underlying cause.
Step 2: By asking the client to elaborate on the reason for the craving, the nurse can assess if it's related to a medical condition or nutritional deficiency.
Step 3: Understanding the client's perspective can guide the nurse in providing appropriate support and interventions.
Step 4: Referring the client to a therapist (option A) without first exploring the issue may not address the root cause effectively.
Step 5: Hypotension (option B) and nasal congestion (option C) are not directly related to the issue of chalk craving, making them incorrect choices.
In summary, option D is correct as it promotes client-centered care by exploring the client's concerns before considering further interventions.
The nurse is reviewing lab results for a pregnant client. Which finding is most concerning?
- A. Hemoglobin of 11 g/dL.
- B. WBC count of 14,000 mm3.
- C. Platelet count of 90,000 mm3.
- D. Fasting blood glucose of 90 mg/dL.
Correct Answer: C
Rationale: The correct answer is C: Platelet count of 90,000 mm3. A low platelet count (thrombocytopenia) in pregnancy can lead to serious complications like bleeding disorders or preeclampsia. Hemoglobin level of 11 g/dL is within normal range for pregnancy. WBC count of 14,000 mm3 may indicate infection but is not as concerning as thrombocytopenia. Fasting blood glucose of 90 mg/dL is also normal in pregnancy.
What is disordered eating?
- A. an occasional overeating episode
- B. a normal variation in eating patterns
- C. a range of abnormal eating behaviors and attitudes
- D. a preference for specific types of foods
Correct Answer: C
Rationale: The correct answer is C because disordered eating refers to a range of abnormal eating behaviors and attitudes that may indicate a potential eating disorder. This includes behaviors such as restrictive dieting, binge eating, purging, or obsessively controlling food intake. Option A is incorrect because an occasional overeating episode does not necessarily indicate disordered eating. Option B is incorrect as disordered eating is not considered a normal variation in eating patterns. Option D is incorrect as having a preference for specific types of foods does not classify as disordered eating unless it leads to serious negative consequences.
The nurse is teaching a client about foods rich in folic acid during pregnancy. Which food should the nurse recommend?
- A. Citrus fruits.
- B. Lean meats.
- C. Dairy products.
- D. Whole grains.
Correct Answer: A
Rationale: The correct answer is A, citrus fruits. Folic acid is important for fetal development and helps prevent birth defects. Citrus fruits like oranges, grapefruits, and lemons are rich sources of folic acid. They provide the necessary nutrients for a healthy pregnancy. Lean meats (B) are good sources of protein but not specifically high in folic acid. Dairy products (C) are important for calcium but do not contain significant amounts of folic acid. Whole grains (D) are beneficial for fiber and nutrients, but they are not the best source of folic acid compared to citrus fruits.