Nokea
The nurse is caring for a client who had a contraction stress test. Which change in assessment requires immediate notification of the health care provider?
- A. No late decelerations
- B. Late decelerations with at least 50% of the contractions
- C. Accelerations with contractions
- D. No contractions produced
Correct Answer: B
Rationale: The correct answer is B because late decelerations with at least 50% of contractions indicate fetal distress and potential hypoxia. This requires immediate notification of the healthcare provider for further evaluation and intervention. No late decelerations (choice A) are normal. Accelerations with contractions (choice C) are reassuring. No contractions produced (choice D) would indicate an inadequate test and require reevaluation.
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The nurse receives a phone call from a pregnant patient who states she has not felt the baby move. Identify the first question for the nurse to ask the patient.
- A. Have you experienced any recent vaginal bleeding?
- B. Have you experienced any recent vaginal discharge?
- C. How many weeks pregnant are you?
- D. When was the last time you felt the baby move?
Correct Answer: D
Rationale: The correct first question for the nurse to ask the patient is D: When was the last time you felt the baby move? This question is crucial because it helps assess the fetal well-being and can indicate any potential issues with the baby's health or development. It allows the nurse to determine if there has been a recent decrease in fetal movements, which could be a sign of distress. Asking about vaginal bleeding or discharge (choices A and B) may not provide immediate insight into the baby's well-being. Question C is relevant but not as urgent as knowing when the baby was last felt moving.
Which of the patient health behaviors in the first trimester would the nurse identify as a risk factor in pregnancy?
- A. Sexual intercourse two or three times weekly
- B. Moderate exercise for 30 minutes daily
- C. Working 40 hours a week as a secretary in a travel agency
- D. Relaxing in a hot tub for 30 minutes a day, several days a week
Correct Answer: D
Rationale: The correct answer is D because relaxing in a hot tub for 30 minutes a day, several days a week can increase the body temperature, which is harmful during the first trimester and can lead to birth defects. Choice A is not a risk factor as it promotes a healthy sexual relationship. Choice B is beneficial as moderate exercise is recommended during pregnancy. Choice C is not necessarily a risk factor unless it involves exposure to harmful substances or excessive stress.
A breastfeeding client asks the nurse to make sure that her newborn is positioned and latched well at the breast. Which of the following assessments would indicate that the baby is poorly latched?
- A. The baby swallows after every suckle.
- B. The baby’s body is facing the mother’s body.
- C. The baby’s lower lip is curled under.
- D. The baby is lying at the level of the mother’s breasts.
Correct Answer: C
Rationale: A curled-under lower lip indicates poor latching, which can lead to ineffective feeding and nipple damage.
A patient in her third trimester of pregnancy is asking about safe travel. Which statement should the nurse provide regarding safe travel during pregnancy?
- A. Only travel by car during pregnancy.'
- B. Avoid use of the seat belt during the third trimester.'
- C. You can travel by plane until your 38th week of gestation.'
- D. If you are traveling by car stop to walk every 1 to 2 hours.'
Correct Answer: D
Rationale: The correct answer is D: "If you are traveling by car, stop to walk every 1 to 2 hours." This is the best advice because it promotes circulation and reduces the risk of blood clots during long car rides. Walking helps prevent stiffness and discomfort.
A: "Only travel by car during pregnancy" is incorrect because other modes of transportation can be safe as well.
B: "Avoid use of the seat belt during the third trimester" is incorrect as wearing a seat belt is crucial for the safety of both the mother and the baby in case of an accident.
C: "You can travel by plane until your 38th week of gestation" is incorrect as most airlines have restrictions on flying after 36 weeks due to the risk of preterm labor.
A baby is exhibiting signs of neonatal abstinence syndrome. Which action would be appropriate for the nursery nurse to make?
- A. Cover the baby with at least two blankets.
- B. Stimulate the baby with rattles.
- C. Play soft classical music in the nursery.
- D. Attach a mobile to the crib.
Correct Answer: A
Rationale: Neonatal abstinence syndrome babies are sensitive to stimuli, so minimizing environmental stimulation, such as by swaddling, is important.