Nokea
Which intervention would the nurse initiate when a fetal heart pattern signifying uteroplacental insufficiency occurs?
- A. Inserting a urinary catheter
- B. Administering oxygen by means of nasal cannula
- C. Helping the client turn to the side-lying position
- D. Encouraging the client to pant with her next contraction
Correct Answer: C
Rationale: The correct answer is C: Helping the client turn to the side-lying position. This intervention facilitates increased blood flow to the placenta, improving oxygenation to the fetus during uteroplacental insufficiency. The side-lying position relieves pressure on the vena cava, enhancing blood flow. Inserting a urinary catheter (A) is not indicated for addressing uteroplacental insufficiency. Administering oxygen (B) is important, but turning the client to the side is the priority as it directly improves blood flow. Encouraging panting (D) is not effective in addressing uteroplacental insufficiency.
You may also like to solve these questions
Which intrapartal assessment should be avoided when caring for a patient with HELLP syndrome?
- A. Abdominal palpation
- B. Venous sample of blood
- C. Checking deep tendon reflexes
- D. Auscultation of the heart and lungs
Correct Answer: A
Rationale: Correct Answer: A - Abdominal palpation
Rationale: Abdominal palpation can lead to increased risk of placental abruption in patients with HELLP syndrome. This can cause severe hemorrhage and compromise fetal and maternal well-being. Therefore, it should be avoided.
Summary of other choices:
- B: Venous sample of blood: Necessary for assessing blood parameters in patients with HELLP syndrome.
- C: Checking deep tendon reflexes: Important for evaluating neurological status in patients with HELLP syndrome.
- D: Auscultation of the heart and lungs: Essential for monitoring cardiovascular and respiratory function in patients with HELLP syndrome.
The labor nurse is admitting a patient in active labor with a history of genital herpes. On assessment, the patient reports a recent outbreak, and the nurse verifies lesions on the perineum. What is the nurse"™s next action?
- A. Ask the patient when she last had anything to eat or drink.
- B. Take a culture of the lesions to verify the involved organism.
- C. Ask the patient if she has had unprotected sex since her outbreak.
- D. Use electronic fetal surveillance to determine a baseline fetal heart rate.
Correct Answer: A
Rationale: The correct answer is A: Ask the patient when she last had anything to eat or drink. This is the correct action because the patient is in active labor with genital herpes lesions. Knowing the last time the patient had anything to eat or drink is essential in case an emergency cesarean section is needed, as the patient may need to be NPO.
Option B: Taking a culture of the lesions is not the immediate priority as the patient is in active labor and the presence of lesions is already confirmed.
Option C: Asking about unprotected sex is important for history taking but not the immediate next action in this scenario.
Option D: Using electronic fetal surveillance is also important, but the priority in this case is assessing the patient's fasting status for potential emergency procedures.
What virus is highly contagious, spread through airborne particles, and can cause intrauterine fetal demise, skin scarring, eye, limb or neurologic abnormalities, anemia, thrombocytopenia, and low birth weight in the fetus?
- A. toxoplasmosis
- B. syphilis
- C. rubella
- D. Varicella (chickenpox)
Correct Answer: D
Rationale: The correct answer is D: Varicella (chickenpox). Varicella virus is highly contagious and spreads through airborne particles. It can cause intrauterine fetal demise, skin scarring, eye, limb, or neurologic abnormalities, anemia, thrombocytopenia, and low birth weight in the fetus. Varicella infection during pregnancy can lead to severe complications for both the mother and the fetus. Toxoplasmosis (A), syphilis (B), and rubella (C) can also cause complications during pregnancy, but they do not match all the characteristics mentioned in the question.
Which finding on a prenatal visit at 10 weeks might suggest a hydatidiform mole?
- A. Blood pressure of 120/80 mm Hg
- B. Complaint of frequent mild nausea
- C. Fundal height measurement of 18 cm
- D. History of bright red spotting for 1 day weeks ago
Correct Answer: C
Rationale: The correct answer is C: Fundal height measurement of 18 cm. At 10 weeks of gestation, the fundal height should typically measure around 10-12 cm. A fundal height measurement of 18 cm would suggest excessive growth, which is a characteristic finding in a hydatidiform mole due to abnormal proliferation of placental tissue.
Incorrect choices:
A: Blood pressure of 120/80 mm Hg is within normal range and not specific to hydatidiform mole.
B: Complaint of frequent mild nausea is a common symptom in early pregnancy and not specific to a mole.
D: History of bright red spotting for 1 day weeks ago is more indicative of a potential previous miscarriage, not necessarily a mole.
A high-risk labor patient progresses from preeclampsia to eclampsia. Aggressive management is instituted, and the fetus is delivered via cesarean birth. Which finding in the immediate postoperative period indicates that the patient is at risk of developing HELLP syndrome?
- A. Platelet count of 50,000/mcL
- B. Liver enzyme levels within normal range
- C. Negative for edema
- D. No evidence of nausea or vomiting
Correct Answer: A
Rationale: The correct answer is A: Platelet count of 50,000/mcL. In HELLP syndrome, there is hemolysis, elevated liver enzymes, and low platelet count. A platelet count of 50,000/mcL indicates thrombocytopenia, a key feature of HELLP syndrome. It signifies ongoing coagulation abnormalities and liver dysfunction.
B: Liver enzyme levels within normal range is incorrect as HELLP syndrome typically presents with elevated liver enzymes.
C: Negative for edema is incorrect as edema is not a defining characteristic of HELLP syndrome.
D: No evidence of nausea or vomiting is incorrect as these symptoms are not specific to HELLP syndrome.