Nokea
A charge nurse is teaching a group of staff nurses about fetal monitoring during labor. Which of the following findings should the charge nurse instruct the staff members to report to the provider?
- A. Contraction durations of 95 to 100 seconds
- B. Contraction frequency of 2 to 3 min apart
- C. Absent early deceleration of fetal heart rate
- D. Fetal heart rate is 140/min
Correct Answer: A
Rationale: The correct answer is A: Contraction durations of 95 to 100 seconds. This is an abnormal finding as typical contraction durations should be around 60-90 seconds. Prolonged contractions can lead to decreased fetal oxygenation and distress. Choice B is incorrect as contractions 2-3 minutes apart are within the normal range. Choice C is incorrect as absent early deceleration is a reassuring sign of fetal well-being. Choice D is incorrect as a fetal heart rate of 140/min is within the normal range of 110-160/min.
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A nurse is caring for a client who reports spontaneous rupture. The nurse observed fetal bradycardia in the FHR tracing and notices the umbilical cord is protruding. After calling for assistance and notifying the provider, which of the following should the nurse take next?
- A. Initiate an infusion of IV fluids for the client
- B. Perform vaginal examination by applying upward pressure on the presenting part
- C. Administer oxygen via non-rebreather mask at 8 L/min
- D. Cover the umbilical cord with sterile saline saturated towel
Correct Answer: D
Rationale: The correct answer is D: Cover the umbilical cord with sterile saline saturated towel. This step is crucial to prevent compression of the umbilical cord and maintain blood flow to the fetus, reducing the risk of fetal distress. It also helps in preventing infection and protecting the exposed cord.
Choice A: Initiating an infusion of IV fluids is not the priority in this situation as the immediate concern is to protect the umbilical cord and ensure fetal well-being.
Choice B: Performing a vaginal examination could further worsen the situation by putting pressure on the umbilical cord, leading to decreased blood flow to the fetus.
Choice C: Administering oxygen is important in fetal distress, but covering the umbilical cord takes precedence in this case to prevent further complications.
In summary, covering the umbilical cord with a sterile saline-saturated towel is the correct action to protect the cord and maintain fetal perfusion.
A nurse on the labor and delivery unit is assessing four clients. Which of the following clients is a candidate for an induction of labor with misoprostol?
- A. A client who has active genital herpes
- B. A client who has gestational diabetes mellitus
- C. A client who has a previous uterine incision
- D. A client who has placenta previa
Correct Answer: B
Rationale: The correct answer is B: A client who has gestational diabetes mellitus. Induction of labor with misoprostol is safe for clients with gestational diabetes mellitus as it does not affect blood glucose levels. Misoprostol is contraindicated in clients with active genital herpes (Choice A) due to risk of viral transmission. It is also contraindicated in clients with a previous uterine incision (Choice C) as it may increase the risk of uterine rupture. Clients with placenta previa (Choice D) should not undergo induction with misoprostol due to the risk of increasing bleeding.
A nurse is planning care for a newborn who is scheduled to start phototherapy using a lap.
- A. Apply a thin layer lotion to the newborn's skin every 8 hours
- B. Dress the newborn in a thin layer of clothing during the therapy
- C. Ensure the newborn's eyes are closed beneath the shield
- D. Give the newborn 1 oz of glucose water every 4 hours
Correct Answer: C
Rationale: The correct answer is C: Ensure the newborn's eyes are closed beneath the shield. During phototherapy, the newborn's eyes need to be protected from the bright lights to prevent potential eye damage. Closing the eyes beneath the shield helps to shield them from the light exposure. This step is crucial in preventing complications and ensuring the safety and well-being of the newborn.
Other choices are incorrect because:
A: Applying lotion to the newborn's skin may interfere with the effectiveness of the phototherapy and is not necessary for the treatment.
B: Dressing the newborn in clothing may also interfere with the effectiveness of the phototherapy as the light needs direct contact with the skin.
D: Giving glucose water every 4 hours is not indicated for phototherapy and may not be appropriate for the newborn's condition.
In summary, ensuring the newborn's eyes are closed beneath the shield is the correct choice as it is essential for the safety and effectiveness of the phototherapy treatment.
A nurse is caring for a client who is in the second stage of labor. Which of the following manifestations should the nurse expect?
- A. The client expels the placenta
- B. The client experiences gradual dilation of the cervix
- C. The client begins have regular contractions.
- D. The client delivers the newborn
Correct Answer: D
Rationale: The correct answer is D. In the second stage of labor, the client delivers the newborn. This stage begins with full dilation of the cervix and ends with the birth of the baby. The expulsion of the placenta (Choice A) occurs in the third stage of labor. Gradual dilation of the cervix (Choice B) is characteristic of the first stage of labor. Regular contractions (Choice C) may occur throughout labor but are not specific to the second stage. So, the correct answer is D because it aligns with the chronological progression of labor stages.
A nurse is teaching a client who is at 41 weeks of gestation about a non-stress test. Which of the following information should the nurse include in the teaching?
- A. This test will confirm fetal lung maturity
- B. This test will determine adequacy of placental perfusion
- C. This test will detect fetal infection
- D. This test will predict maternal readiness for labor
Correct Answer: B
Rationale: The correct answer is B: This test will determine the adequacy of placental perfusion. A non-stress test is used to assess fetal well-being by monitoring the fetal heart rate in response to fetal movement. The test helps determine if the placenta is providing enough oxygen to the fetus. Adequate placental perfusion is crucial for the well-being of the fetus. Option A is incorrect because a non-stress test does not confirm fetal lung maturity. Option C is incorrect because a non-stress test does not detect fetal infection. Option D is incorrect because a non-stress test does not predict maternal readiness for labor.