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A nurse in a prenatal clinic is caring for a client who is at 39 weeks of gestation and who asks about the signs that precede the onset of labor. Which of the following should the nurse identify as a sign that precedes labor?
- A. Decreased vaginal discharge
- B. A surge of energy
- C. Urinary retention
- D. Weight gain of 0.5 to 1.5 kg
Correct Answer: B
Rationale: The correct answer is B: A surge of energy. This is because an increase in energy is often seen in pregnant women shortly before labor begins, known as the "nesting instinct." This burst of energy can indicate that the body is preparing for labor.
A: Decreased vaginal discharge is not a sign that precedes labor. In fact, an increase in vaginal discharge is more common as labor approaches.
C: Urinary retention is not a sign of labor onset. In late pregnancy, pressure on the bladder may cause frequent urination, but retention is not typical.
D: Weight gain of 0.5 to 1.5 kg is not a specific sign of labor onset. Weight gain can fluctuate throughout pregnancy and is not a reliable indicator of impending labor.
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A nurse is teaching a prenatal class about immunizations that newborns receive following birth. Which of the following immunizations should the nurse include in the teaching?
- A. Hepatitis B
- B. Rotavirus
- C. Pneumococcal
- D. Varicella
Correct Answer: A
Rationale: The correct answer is A: Hepatitis B. Newborns typically receive the Hepatitis B vaccine shortly after birth to provide protection against the virus. This is important because newborns are at risk of contracting Hepatitis B from infected mothers during childbirth. The vaccine helps prevent chronic liver infections and liver cancer later in life.
Why other choices are incorrect:
B: Rotavirus - Rotavirus vaccine is typically given to infants starting at 2 months of age, not immediately after birth.
C: Pneumococcal - Pneumococcal vaccines are usually given later in infancy, not right after birth.
D: Varicella - Varicella vaccine is typically given around 12-15 months of age, not immediately after birth.
The nurse is assessing a client with hyperemesis gravidarum. What lab finding is most concerning?
- A. Elevated hematocrit.
- B. Decreased potassium.
- C. Increased white blood cell count.
- D. Low fasting blood glucose.
Correct Answer: B
Rationale: The correct answer is B: Decreased potassium. In hyperemesis gravidarum, excessive vomiting can lead to electrolyte imbalances, particularly hypokalemia. Potassium plays a crucial role in nerve and muscle function, so a low potassium level can result in serious complications such as cardiac arrhythmias. Elevated hematocrit (A) may indicate dehydration, but it is not as immediately concerning as potassium imbalance. Increased white blood cell count (C) may suggest infection but is not directly related to hyperemesis gravidarum. Low fasting blood glucose (D) can occur due to inadequate nutrient intake but is not the most concerning finding in this case.
The nurse is caring for a client in labor with a history of cesarean delivery. What is a priority assessment?
- A. Assess for signs of uterine rupture.
- B. Monitor maternal temperature hourly.
- C. Check for signs of preeclampsia.
- D. Assess for excessive fetal movement.
Correct Answer: A
Rationale: The correct answer is A: Assess for signs of uterine rupture. This is the priority assessment because a history of cesarean delivery puts the client at higher risk for uterine rupture during labor. Signs of uterine rupture include severe abdominal pain, abnormal fetal heart rate patterns, and vaginal bleeding. Early detection and intervention are crucial for the safety of both the mother and the baby. Monitoring maternal temperature (B) is important but not as critical as assessing for uterine rupture. Checking for signs of preeclampsia (C) is also important but not a priority in this specific scenario. Assessing for excessive fetal movement (D) is not a priority assessment in this case.
A nurse is caring for a client who is 1 hr postpartum and observes a large amount of lochia rubra and several small clots on the client's perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take?
- A. Document the findings and continue to monitor the client.
- B. Notify the client's provider.
- C. Increase the frequency of fundal massage.
- D. Encourage the client to empty her bladder.
Correct Answer: A
Rationale: The correct answer is A: Document the findings and continue to monitor the client. This is the appropriate action because the client's fundus is midline and firm, indicating good uterine tone. Lochia rubra and small clots are expected findings in the immediate postpartum period. The nurse should document these findings for future reference and continue to monitor the client's condition.
Choice B (Notify the client's provider) is incorrect because there are no concerning signs that warrant immediate provider notification, as the fundus is firm and midline.
Choice C (Increase the frequency of fundal massage) is unnecessary since the fundus is already firm at the umbilicus, indicating good uterine tone.
Choice D (Encourage the client to empty her bladder) is not the priority in this scenario, as the client's fundal assessment and lochia observations take precedence.
A patient has just been admitted to labor and delivery. She is having mild contractions lasting 30 seconds every 15 minutes. The patient wants to have a mediation free birth. When discussing medication alternatives, the nurse should be sure the patient understands that:
- A. maternal pain and stress can have a more adverse effect on the fetus than a small amount of analgesia
- B. In order to respect her wishes no pain medication will be given
- C. the use of medication allows the patient to rest and be less fatigued
- D. pain relief will allow a more enjoyable birth experience
Correct Answer: A
Rationale: The correct answer is A because maternal pain and stress can lead to increased levels of stress hormones, which can negatively affect the fetus. By providing a small amount of analgesia, the patient can experience relief from pain and stress without compromising the well-being of the fetus.
Option B is incorrect because it disregards the potential benefits of providing some pain relief to the patient while still respecting her desire for a medication-free birth.
Option C is incorrect because while medication may provide some rest and alleviate fatigue, the primary concern in this scenario is the impact on the fetus rather than the patient's comfort.
Option D is incorrect because the main focus should be on ensuring the safety and well-being of both the mother and the fetus, rather than solely on the mother's enjoyment of the birth experience.