Nokea
A laboring woman, G4 P3003, who was 6 cm dilated 1 hour ago cries, 'Hurry. I have to go to the bathroom to have a bowel movement.' The nurse notes that there is an increase in bloody show. Which of the following actions by the nurse is appropriate?
- A. Assess cervical dilation.
- B. Help the woman to the bathroom.
- C. Ask the woman if she needs pain medicine.
- D. Check the fetal heart rate.
Correct Answer: A
Rationale: The urge to have a bowel movement and increased bloody show could indicate that the woman is entering the second stage of labor. The nurse should assess cervical dilation to confirm.
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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.
The nurse who has just performed a vaginal examination notes that the fetus is in the LOP position. Which of the following clinical assessments would the nurse expect to note at this time?
- A. Complaints of severe back pain.
- B. Rapid descent and effacement.
- C. Irregular and hypotonic contractions.
- D. Rectal pressure with bloody show.
Correct Answer: A
Rationale: The LOP (left occiput posterior) position often causes back pain due to the fetal head pressing against the mother’s sacrum.
An NST is performed on a client who is G6T3P1A1L4 38 weeks gestation. After the patient has been on the external monitor for 30 minutes, the nurse sees three fetal heart rate accelerations of 15 bpm lasting 5 seconds in association with fetal movement. The nurse documents this finding as which of the following?
- A. Unsatisfactory
- B. A reactive NST
- C. A nonreactive nonstress test
- D. Equivocal suspicious
Correct Answer: B
Rationale: The correct answer is B: A reactive NST. This is because the NST shows three fetal heart rate accelerations of 15 bpm lasting 5 seconds each, in association with fetal movement. A reactive NST indicates a normal response, which is characterized by the presence of fetal heart rate accelerations associated with fetal movement. This is a reassuring finding, suggesting fetal well-being.
Choice A (Unsatisfactory) is incorrect because the description of the findings indicates a satisfactory response. Choice C (A nonreactive nonstress test) is incorrect because the test showed accelerations in response to fetal movements, which is not consistent with a nonreactive test. Choice D (Equivocal suspicious) is incorrect as there is no indication of uncertainty or suspicion in the findings described.
A G1 P0000 gravida, whose labor was uneventful, delivered 1 minute ago. The baby’s Apgar score at this time is 3. Which of the following actions is appropriate for the nurse to make?
- A. Administer ophthalmic prophylaxis.
- B. Place the baby on the abdomen of the mother.
- C. Obtain assistance for neonatal resuscitation.
- D. Repeat the score to confirm its accuracy.
Correct Answer: C
Rationale: An Apgar score of 3 indicates the baby is in distress and requires immediate neonatal resuscitation.
The nurse is caring for a baby whose blood type is A+ (positive) and direct Coombs’ test is + (positive), and whose mother’s blood type is O+ (positive). Which of the following nursing diagnoses is appropriate for this baby?
- A. Risk for injury to the central nervous system.
- B. Risk for fluid volume deficit.
- C. Risk for interrupted family processes.
- D. Risk for impaired parent-infant attachment.
Correct Answer: A
Rationale: A positive Coombs’ test indicates hemolytic disease of the newborn, which can lead to bilirubin buildup and potential central nervous system damage.