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A client comes to the labor and delivery with polyhydramnios. She was admitted and her membrane ruptures is clear and odorless, but the fetal heart monitor indicate bradycardia and variable decelerations. What should action should be taken next?
- A. Perform vaginal exam (lot of fluid, check to see where baby is)
- B. High fowler position
- C. Warm saline soak vaginal
- D. Perform Leopold maneuver
Correct Answer: A
Rationale: In this scenario, with the presence of polyhydramnios and clear, odorless amniotic fluid, the fetal heart monitor indicating bradycardia and variable decelerations indicates a potential umbilical cord compression due to excessive amniotic fluid volume. It is crucial to perform a vaginal exam promptly as this can help assess the position of the baby and determine if there is a cord prolapse or any other complications that may be affecting the fetal heart rate. The baby's position needs to be identified quickly to address potential issues and ensure a safe delivery process.
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A client, who is in the second trimester of pregnancy, gestation. The client is receiving magnesium sulfate tells the nurse that she has developed a reddish-pink intravenously for pre-eclampsia. Which assessment skin color on the palm of her hands. Which of the fol- requires immediate intervention?
- A. Blood pressure of 130/90 mm Hg
- B. Urine output of 20 mL in past hour
- C. Facial flushing
- D. Patellar reflexes 2+
Correct Answer: C
Rationale: Facial flushing in a pregnant client receiving magnesium sulfate for pre-eclampsia can be a sign of magnesium toxicity. Magnesium sulfate is a tocolytic agent used to prevent seizures in pre-eclamptic patients; however, excessive levels of magnesium can cause symptoms such as flushing, lethargy, blurred vision, slurred speech, and muscle weakness. In severe cases, magnesium toxicity can progress to respiratory depression, cardiac arrest, and death. Therefore, immediate intervention is required to prevent further complications. The other options do not present immediate concerning signs related to magnesium toxicity.
The nurse is performing an assessment on a client who is at 38 weeks' gestation and notes that the fetal heart rate is 174 beats/minute. What is the priority nursing action?
- A. Document the finding.
- B. Check the mother's heart rate.
- C. Notify the health care provider (HCP).
- D. Tell the client that the fetal heart rate is normal.
Correct Answer: C
Rationale: A fetal heart rate above 160 bpm at term may indicate fetal distress, requiring immediate notification of the HCP.
A male infant delivered at 28 weeks gestation weighs 2 pounds, 12 ounces. When performing an assessment, the nurse would probably observe:
- A. Wide, staring eye
- B. Transparent, red skin
- C. An absence of lanugo
- D. A scrotum with descended testicles
Correct Answer: B
Rationale: A male infant delivered at 28 weeks gestation, as described, would likely have very underdeveloped skin due to the premature birth. The premature skin is often transparent, allowing the prominent blood vessels underneath to be visible, and may also have a reddish hue due to the skin's immaturity. This characteristic appearance is a common finding in premature infants and is a result of their skin being thinner and more fragile than that of full-term infants. The other options, such as a wide, staring eye, an absence of lanugo, and a scrotum with descended testicles, are not specifically associated with premature birth and are not likely to be observed in this scenario.
A Nurse is caring for a client who is 36 weeks9 gestation and who has suspected placenta previa. Which of the following findings support this diagnosis? Intermitted abdominal pain following the passage Abdominal pain with scant red vaginal bleeding Increasing abdominal pain with non-relaxed Painless red vaginal bleeding Dosage 200 A women at 36 weeks of gestation is placed in a supine position for an ultrasound. She begins to complain about feeling dizzy and nauseated. Her skin feels damp and cool. what would be the nurse9s first action? Obtain vital signs Provide the woman with emesis basin Turn the woman on her side Assess the woman9s respiratory rate and effort The nurse explains to a newly diagnosed pregnant woman at 10 weeks9 gestation that her rubella titer indicates that she is not immune. What is the best response by the nurse? Avoid contact with all children during the pregnancy You should receive the rubella vaccine immediately Obtain a repeat tilter in 3 months You will receive the rubella vaccine during the postpartumperiod The clinic nurse explains to Margaret, a newly diagnosed pregnant woman at 10 weeks' gestation, that her rubella titer indicates that she is not immune. Margaret should be advised to (select all that apply): Select one or more:
- A. Avoid contact with all children
- B. Be retested in 3 months c.Receive the rubella vaccine postpartum
- C. Report signs or symptoms of fever, runny nose, and generalized red rash to the health-care provider C, D Filter and block all substances from reaching the fetus Stops estrogen production Provide nutrition to the fetus Provide antibiotics to the fetus Which of the following is NOT a function of the placenta?
- D. respiratory gas transfer
Correct Answer: C
Rationale: The functions of the placenta primarily include nutrient transfer, hormone production, respiratory gas transfer, and waste elimination. The placenta does not have a role in urine formation. Urine formation is a function of the kidneys in the mother, and it is not directly related to the placenta's functions.
The nurse assesses a patient for medical eligibility for contraceptive use. What is the meaning of an MEC score of 1?
- A. There is no restriction for the use of the contraceptive method.
- B. There is an unacceptable health risk if the contraceptive method is used.
- C. There is a risk that outweighs the advantages of the contraceptive method.
- D. There is an advantage of using a contraceptive method that outweighs any risk.
Correct Answer: A
Rationale: In the context of medical eligibility for contraceptive use, an MEC (Medical Eligibility Criteria) score of 1 indicates that there are no restrictions for using the particular contraceptive method. A score of 1 suggests that the advantages of using the contraceptive method outweigh any potential risks, making it a safe and recommended choice for the patient. Therefore, a patient with an MEC score of 1 can use the contraceptive method without any concerns regarding health risks or restrictions.