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A fetal fibronectin assessment of the cervicovaginal fluids of a 28-week gravida is positive. Based on the results, which of the following complaints should the nurse advise the client to report immediately to the health care provider?
- A. Headache.
- B. Visual disturbances.
- C. Uterine cramping.
- D. Oliguria.
Correct Answer: C
Rationale: Uterine cramping may indicate preterm labor, which is a concern with a positive fetal fibronectin test.
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Which laboratory result would be a cause for concern if exhibited by a patient at her first prenatal visit during the second month of her pregnancy?
- A. Rubella titer, 1:6
- B. Platelets, 300,000/mm3
- C. White blood cell count, 6000/mm3
- D. Hematocrit 38%, hemoglobin 13 g/dL
Correct Answer: A
Rationale: The correct answer is A: Rubella titer, 1:6. A low rubella titer indicates susceptibility to rubella infection, which can be harmful during pregnancy. Rubella can lead to birth defects or miscarriage. Platelets, WBC count, and hematocrit/hemoglobin levels are within normal range and not typically concerning during the early stages of pregnancy.
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 4-day-old breastfeeding neonate, whose birth weight was 2,678 grams, has lost 286 grams since its cesarean birth. Which of the following actions should the nurse take?
- A. Nothing, because this is an acceptable weight loss.
- B. Advise the mother to stop breastfeeding and give formula.
- C. Notify the neonatologist of the excessive weight loss.
- D. Give the baby dextrose water between breast feedings.
Correct Answer: A
Rationale: A weight loss of up to 10% of birth weight in the first week is considered normal for breastfed neonates.
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.
A pregnant patient asks the prenatal nurse how much physical activity is safe during pregnancy. What is an acceptable response by the nurse?
- A. Decreasing physical activity decreases emotional and physical symptoms.
- B. Increasing physical activity increases emotional and physical symptoms.
- C. Physical activity during pregnancy should be limited to hygiene and household tasks.
- D. The level of activity prior to pregnancy is used to determine a safe activity level during pregnancy.
Correct Answer: D
Rationale: The correct answer is D because the level of activity prior to pregnancy is a good indicator of the safe activity level during pregnancy. This is because pregnant women are generally encouraged to continue their pre-pregnancy level of exercise, adjusting as needed based on individual circumstances.
A is incorrect because decreasing physical activity may lead to more physical discomfort and emotional symptoms. B is incorrect as increasing physical activity can be beneficial if done safely. C is incorrect because hygiene and household tasks alone may not provide sufficient physical activity during pregnancy.