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The nurse is caring for a client in labor with her third baby. She is 39 weeks gestation, 6 cm dilated, 80% effaced, and 0 station, with minimal variability and recurrent variable decelerations. What action is the highest priority for the nurse?
- A. Administer oxygen
- B. Change maternal position
- C. Perform fetal scalp stimulation
- D. Perform vaginal examination
Correct Answer: B
Rationale: The correct answer is B: Change maternal position. This is the highest priority because the client is experiencing recurrent variable decelerations, which can indicate umbilical cord compression. Changing the maternal position can help relieve the pressure on the cord, potentially improving fetal oxygenation. Administering oxygen (choice A) can be important but addressing the cause of the variable decelerations is crucial. Performing fetal scalp stimulation (choice C) is not appropriate at this time as the focus should be on improving fetal oxygenation. Performing a vaginal examination (choice D) is not necessary at this moment and may even exacerbate the situation.
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The nurse has admitted a client who is 30 weeks gestation with suspected intrauterine growth restriction. The physician has ordered a Doppler blood flow study. What does the nurse suspect if the results show an S/D ratio above the 95th percentile for the gestational age, a ratio above 3, or end-diastolic blood flow that is absent or reversed?
- A. Decreased blood pressure
- B. Placental insufficiency
- C. Increased amniotic fluid
- D. Decreased fetal movement
Correct Answer: B
Rationale: The correct answer is B: Placental insufficiency. An elevated S/D ratio (>95th percentile for gestational age or >3) and absent/reversed end-diastolic blood flow on Doppler study indicate impaired placental blood flow, leading to decreased oxygen and nutrient delivery to the fetus. This can result in intrauterine growth restriction (IUGR) and compromise fetal well-being. Decreased blood pressure (A) is not directly related to these Doppler findings. Increased amniotic fluid (C) is more commonly associated with conditions like fetal anomalies or maternal diabetes. Decreased fetal movement (D) may be a sign of fetal distress but is not specifically indicated by Doppler findings in IUGR.
A nurse hears a co-worker state that anybody could be a nurse since it is so automated with infusion devices and electronic monitoring; technology is doing the work. What is the nurse’s best response?
- A. Technology use has to be combined with nursing judgment.
- B. The focus of effective nursing care is technology.
- C. If it’s so easy, why don’t you do it?
- D. That is true in the 20th century.
Correct Answer: A
Rationale: In many ways, technology makes work easier, but it does not replace nursing judgment. Technology does not replace your critical eye and clinical judgment. Most importantly, it is essential to remember that the focus of nursing care is not the machine or the technology; it is the patient.
The labor nurse is reviewing breathing techniques with a primiparous patient admitted for induction of labor. When is the best time to encourage the laboring patient to use slow, deep chest breathing with contractions?
- A. During labor, when she can no longer talk through contractions
- B. During the first stage of labor, when the contractions are 3 to 4 minutes apart
- C. Between contractions, during the transitional phase of the first stage of labor
- D. Between her efforts to push to facilitate relaxation between contractions
Correct Answer: A
Rationale: The correct answer is A: During labor, when she can no longer talk through contractions. This is the best time to encourage slow, deep chest breathing as it helps the laboring patient stay calm, focused, and manage pain effectively during the intense active phase of labor. When a woman reaches the point where she can no longer talk through contractions, it indicates that she is in the active phase of labor and may benefit from slow, deep breathing to help cope with the intensity of contractions.
Explanation for why other choices are incorrect:
B: During the first stage of labor, when the contractions are 3 to 4 minutes apart - Contractions being 3 to 4 minutes apart may not necessarily indicate the active phase of labor requiring slow, deep breathing.
C: Between contractions, during the transitional phase of the first stage of labor - Transitional phase contractions are typically intense and close together, making it less ideal for relaxation breathing between contractions.
D: Between her efforts
A postpartum client, who delivered her baby vaginally 2 hours earlier, just voided 100 mL in the bathroom. After returning to bed, the nurse makes the following assessment: fundus 4 cm above the umbilicus and deviated to the right with moderate lochia rubra. Which of the following nursing diagnoses is appropriate at this time?
- A. Impaired skin integrity.
- B. Fluid volume deficit.
- C. Impaired urinary elimination.
- D. Toileting self-care deficit.
Correct Answer: C
Rationale: A deviated fundus and moderate lochia rubra suggest urinary retention, which can impede uterine involution.
A client, who is 6 hours post–vaginal delivery, has a BP of 150/110. Her last 4 BP readings were: 114/88, 120/80, 134/86, 140/90. Which of the following questions should the nurse ask the client at this time?
- A. Have you had a bowel movement since delivery?'
- B. Is there anything that is making you anxious about the baby?'
- C. When you last went to the bathroom were you bleeding heavily?'
- D. Do you have a headache or blurring of your vision?'
Correct Answer: D
Rationale: Headache or blurring of vision could indicate postpartum preeclampsia, a serious condition requiring immediate intervention.