Nokea
A client at 36 weeks' gestation reports decreased fetal movement. What is the nurse's priority action?
- A. Perform a nonstress test.
- B. Encourage the client to drink orange juice.
- C. Schedule an ultrasound.
- D. Notify the healthcare provider.
Correct Answer: A
Rationale: A nonstress test evaluates fetal well-being and is the first step in assessing decreased fetal movement.
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The nurse is monitoring a client at 39 weeks' gestation receiving oxytocin for labor induction. What finding requires the nurse to stop the infusion?
- A. Contractions every 2–3 minutes.
- B. Contractions lasting 120 seconds.
- C. Baseline fetal heart rate of 140 beats/minute.
- D. Client reports mild back pain.
Correct Answer: B
Rationale: Contractions lasting longer than 90 seconds indicate uterine hyperstimulation and can compromise fetal oxygenation.
The patient asks the nurse when her Nexplanon can be inserted. How does the nurse respond?
- A. after the delivery of your placenta
- B. only during your period
- C. while you are in labor
- D. during the delivery
Correct Answer: A
Rationale: The nurse would respond with option A, "after the delivery of your placenta." Nexplanon is a hormonal contraceptive implant that is typically inserted in the upper arm subdermally. It is recommended to wait until after the delivery of the placenta to reduce the risk of causing any harm to the fetus during pregnancy or labor. Inserting Nexplanon during labor or delivery is not recommended due to the potential risks involved.
A nurse is caring for a client who is in the first stage of labor. The nurse observes the umbilical cord protruding from the vagina. Which of the following actions should the nurse perform first?
- A. Cover the cord with a sterile, moist saline dressing.
- B. Prepare the client for an immediate birth.
- C. Place the client in knee-chest position.
- D. Insert a gloved hand into the vagina to relieve pressure on the cord. Rationale: This is the first nursing action because it is essential to prevent any pressure on the umbilical cord to promote oxygenation of the fetus.
Correct Answer: D
Rationale: The correct action for the nurse to perform first when observing the umbilical cord protruding from the vagina during the first stage of labor is to insert a gloved hand into the vagina to relieve pressure on the cord. This is crucial to prevent compression of the cord, which could compromise oxygenation to the fetus. By gently lifting the presenting part off the cord, the nurse can help maintain blood flow and prevent fetal distress. Once the pressure on the cord is relieved, additional interventions such as preparing the client for immediate birth, covering the cord with a sterile, moist saline dressing, or positioning the client in knee-chest position may be necessary depending on the clinical situation. But the priority is to relieve pressure on the umbilical cord promptly to ensure the well-being of the fetus.
What role do nurses play in addressing social determinants of health (SDOH)?
- A. Nurses primarily focus on providing medical treatments and interventions.
- B. Nurses have no role in addressing social determinants of health.
- C. Nurses are crucial in identifying and addressing the environmental factors that impact health outcomes.
- D. Nurses solely focus on the physical well-being of individuals and do not address social factors.
Correct Answer: C
Rationale:
A nurse is caring for a client who is in the first stage of labor, undergoing external fetal monitoring, and receiving IV fluid. The nurse observes variable decelerations in the fetal heart rate on the monitor strip. Which of the following is a correct interpretation of this finding?
- A. Variable decelerations are due to umbilical cord compression.
- B. Variable decelerations are caused by uteroplacental insufficiency.
- C. Variable decelerations are a result of the administration of IV narcotic analgesics.
- D. Variable decelerations are related to fetal head compression.
Correct Answer: A
Rationale: Variable decelerations in the fetal heart rate are due to umbilical cord compression. These decelerations are characterized by an abrupt decrease in the fetal heart rate that is variable in duration, depth, and timing in relation to the uterine contraction. They can signify compression of the umbilical cord leading to transient interruption of fetal oxygen supply. It is essential for the nurse to promptly identify variable decelerations and take appropriate actions to alleviate the compression, such as repositioning the client to relieve pressure on the cord.