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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. Prolonged contractions can indicate uterine hyperstimulation, leading to decreased fetal oxygenation. Staff should report this to the provider for further evaluation and management.
Explanation:
1. Contraction durations of 95 to 100 seconds are prolonged and may indicate uterine hyperstimulation, potentially compromising fetal oxygenation.
2. Reporting this finding to the provider allows for timely intervention to prevent fetal distress.
3. Choices B, C, and D do not directly indicate a concern for fetal well-being during labor and would not require immediate reporting to the provider.
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A client at 38 weeks' gestation is admitted for decreased fetal movement. What diagnostic test should the nurse anticipate?
- A. Amniocentesis.
- B. Biophysical profile (BPP).
- C. Contraction stress test.
- D. Maternal serum alpha-fetoprotein (MSAFP).
Correct Answer: B
Rationale: The correct answer is B: Biophysical profile (BPP). At 38 weeks' gestation with decreased fetal movement, BPP is used to assess fetal well-being by evaluating fetal heart rate, fetal movements, fetal tone, amniotic fluid volume, and sometimes placental function. It provides immediate information on fetal status and is non-invasive. Amniocentesis (A) is not indicated for decreased fetal movement. Contraction stress test (C) is contraindicated due to the risk of inducing contractions in a term pregnancy. Maternal serum alpha-fetoprotein (D) is a screening test for neural tube defects and is not relevant in this situation.
A client at 28 weeks' gestation is undergoing a glucose tolerance test. What is the purpose of this test?
- A. To detect anemia.
- B. To screen for gestational diabetes.
- C. To assess fetal growth.
- D. To evaluate placental function.
Correct Answer: B
Rationale: The correct answer is B: To screen for gestational diabetes. The glucose tolerance test during pregnancy helps to identify women at risk for developing gestational diabetes, a condition that can lead to complications for both the mother and baby. By measuring blood sugar levels after consuming a glucose solution, healthcare providers can assess how the body processes sugar during pregnancy. This test is specifically designed to detect abnormalities in glucose metabolism during pregnancy.
Choice A: To detect anemia - Anemia is not typically identified through a glucose tolerance test. Anemia is usually diagnosed through a blood test that measures hemoglobin levels.
Choice C: To assess fetal growth - Fetal growth is usually monitored through ultrasound scans and measurements, not through a glucose tolerance test.
Choice D: To evaluate placental function - Placental function is evaluated through other tests like Doppler ultrasound, not through a glucose tolerance test.
The nurse is teaching the postpartum client about newborn transitional stool. Which should the nurse include in the teaching session? SATA
- A. They have greenish brown color
- B. They are looser consistency
- C. They are seedy with sweet sour smell
- D. They have tar like consistency
Correct Answer: A
Rationale: The correct answer is A because transitional stools in newborns typically have a greenish-brown color due to the presence of meconium and the changing composition of the stool as the baby starts digesting breastmilk or formula.
Rationale:
1. A: Greenish-brown color is characteristic of transitional stools as meconium is being passed out.
Incorrect answers:
2. B: Transitional stools are not necessarily looser in consistency.
3. C: Transitional stools are not typically described as seedy with a sweet-sour smell.
4. D: Tar-like consistency is more indicative of meconium, not transitional stools.
A nurse is caring for a client who is at 40 weeks gestation and is in active labor. The client has 6 cm of cervical dilation and 100% cervical effacement. The nurse obtains the client's blood pressure reading as 82/52 mm Hg. Which of the following nursing interventions should the nurse perform?
- A. Prepare for a cesarean birth.
- B. Assist the client to an upright position.
- C. Prepare for an immediate vaginal delivery.
- D. Assist the client to turn onto her side.
Correct Answer: D
Rationale: Correct Answer: D - Assist the client to turn onto her side.
Rationale:
1. Side-lying position improves placental perfusion and circulation, optimizing blood pressure.
2. This position also helps in relieving pressure on major blood vessels, preventing hypotension.
3. It is a non-invasive intervention that can be quickly implemented in the labor setting.
Summary of Other Choices:
A: Preparing for a cesarean birth is not indicated based solely on the client's blood pressure reading.
B: Assisting the client to an upright position may further decrease blood pressure and compromise perfusion.
C: Immediate vaginal delivery is not warranted solely based on the client's blood pressure and cervical dilation.
What hormone is responsible for the development and maturation of the ovarian follicles?
- A. follicle-stimulating hormone (FSH)
- B. luteinizing hormone (LH)
- C. estrogen
- D. progesterone
Correct Answer: A
Rationale: Rationale: Follicle-stimulating hormone (FSH) is responsible for the development and maturation of ovarian follicles by stimulating them to grow and produce estrogen. FSH plays a crucial role in the menstrual cycle and acts on the ovaries to promote follicular development. LH surge triggers ovulation, estrogen is produced by the developing follicles and progesterone is primarily produced after ovulation by the corpus luteum. Therefore, A is correct as it directly influences the growth and maturation of ovarian follicles.