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A client at 28 weeks' gestation with gestational diabetes is undergoing a nonstress test. What is a reassuring result?
- A. Two accelerations in 20 minutes.
- B. Fetal heart rate of 170 beats/minute.
- C. Decreased fetal movement.
- D. Variable decelerations.
Correct Answer: A
Rationale: The correct answer is A: Two accelerations in 20 minutes. Accelerations in fetal heart rate during a nonstress test indicate fetal well-being and adequate oxygenation. Two accelerations in 20 minutes are reassuring as they show a normal response to fetal movement and suggest a healthy fetal nervous system.
Option B is incorrect because a fetal heart rate of 170 beats/minute may indicate fetal distress or tachycardia. Option C is incorrect as decreased fetal movement can be a sign of fetal compromise. Option D is incorrect as variable decelerations can indicate umbilical cord compression and require further evaluation.
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In addition to the bolus of fluid which medication should she be given to increase blood pressure?
- A. Ephedrine
- B. Terbutaline
- C. Epinephrine
- D. Epifoam
Correct Answer: A
Rationale: The correct answer is A: Ephedrine. Ephedrine is a sympathomimetic amine that acts on alpha and beta adrenergic receptors to increase blood pressure. It is commonly used to treat hypotension. Terbutaline (B) and Epinephrine (C) are bronchodilators that can lower blood pressure. Epifoam (D) is a topical medication for skin conditions and does not affect blood pressure. Therefore, Ephedrine is the most appropriate choice to increase blood pressure in this scenario.
The nurse would classify a newborn delivered at 39 weeks' gestation, weighing 2400 g ( 5.0 lbs) as being:
- A. Preterm and immature
- B. Small-for-gestational age
- C. Average-for-gestational age
- D. Average-for-gestational age but pre-term
Correct Answer: B
Rationale: The correct answer is B: Small-for-gestational age. A newborn delivered at 39 weeks' gestation and weighing 2400g is considered small-for-gestational age because the weight is below the 10th percentile for the gestational age. This indicates intrauterine growth restriction. Preterm and immature (choice A) would not apply as the baby was delivered at term. Average-for-gestational age (choice C) would not be accurate as the baby's weight is below the normal range for that gestational age. Choice D is also incorrect as the baby is not within the average weight range for the gestational age.
A nurse is developing an educational program about hemolytic diseases in newborns for a group of newly licensed nurses. Which of the following genetic information should the nurse include in the program as a cause of hemolytic disease?
- A. The mother is Rh positive, and the father is Rh negative
- B. The mother is Rh negative, and the father is Rh positive
- C. The mother and the father are both Rh positive
- D. The mother and the father are both Rh negative
Correct Answer: B
Rationale: The correct answer is B: The mother is Rh negative, and the father is Rh positive. This combination can lead to hemolytic disease in newborns due to Rh incompatibility. If the mother is Rh negative and the father is Rh positive, there is a chance that the fetus may inherit the Rh-positive factor from the father, causing the mother's immune system to produce antibodies against the Rh factor in subsequent pregnancies, potentially leading to hemolytic disease in newborns.
Incorrect choices:
A: The mother is Rh positive, and the father is Rh negative - This combination does not result in Rh incompatibility as the fetus will not inherit the Rh-negative factor from the father.
C: The mother and the father are both Rh positive - Rh incompatibility occurs when the mother is Rh negative and the father is Rh positive, so this choice is incorrect.
D: The mother and the father are both Rh negative - In this case, there is no Rh incompatibility present,
The nurse practicing in a labor setting knows the woman most at risk for a uterine rupture is:
- A. G4 who had all 4 c/s birth
- B. G5 who had 2 vaginal birth and 2 c/s births
- C. G2 low segment vertical incision for delivery of 10lb infant
- D. G3 who had 2 lower segment transverse c/s birth
Correct Answer: C
Rationale: The correct answer is C because a low segment vertical incision for delivery of a large infant (10lb) puts the woman at the highest risk for uterine rupture. This type of incision weakens the uterine wall, increasing the likelihood of rupture during subsequent pregnancies or labor. Choices A, B, and D involve lower segment transverse c-section births, which are less likely to result in uterine rupture compared to a vertical incision. Additionally, the number of previous births or the mode of delivery does not increase the risk of uterine rupture as much as the type of uterine incision.
A nurse is assessing a client who received magnesium sulfate to treat preterm labor. Which of the following clinical findings should the nurse identify as an indication of toxicity of magnesium sulfate therapy and report to the provider?
- A. Respiratory depression
- B. Facial flushing
- C. Nausea
- D. Drowsiness
Correct Answer: A
Rationale: The correct answer is A: Respiratory depression. Respiratory depression is a serious sign of magnesium sulfate toxicity as it can progress to respiratory arrest. Magnesium sulfate acts as a central nervous system depressant, leading to muscle weakness and respiratory depression. Facial flushing is a common side effect but not indicative of toxicity. Nausea and drowsiness are common side effects of magnesium sulfate therapy and are not specific signs of toxicity. Reporting respiratory depression promptly is crucial to prevent further complications.