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A mother, 39 weeks’ gestation, is admitted to the labor suite with rupture of membranes 15 minutes earlier and contractions q 8 minutes × 30 seconds. On vaginal exam, the cervix is 4 cm dilated and 80% effaced, and the station is –2. The baby is found to be in the LSP position. The fetal heart rate is 144 with average variability and variable decelerations. Which of the following complications of labor must the nurse assess this client for at this time?
- A. Precipitous delivery.
- B. Chorioamnionitis.
- C. Uteroplacental insufficiency.
- D. Prolapsed cord.
Correct Answer: D
Rationale: LSP (left sacrum posterior) position and rupture of membranes increase the risk of a prolapsed umbilical cord, which is a medical emergency.
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The nurse is teaching a new mother about the physical characteristics and needs of her baby. Which of the following statements should the nurse include in her discussion?
- A. The anterior fontanelle will close by the time the baby is 18 months of age.'
- B. The grasp reflex will last until the baby is about 10 months old.'
- C. Your baby can see shapes but will not be able to see colors clearly for about 6 months.'
- D. Your baby will likely be started on solid foods when he is 2 to 3 months of age.'
Correct Answer: A
Rationale: The anterior fontanelle typically closes by 18 months of age. The other statements are incorrect or misleading.
Which of the following complications of labor and delivery may develop when a baby enters the pelvis in the LMP position?
- A. Cephalopelvic disproportion.
- B. Placental abruption.
- C. Breech presentation.
- D. Acute fetal distress.
Correct Answer: A
Rationale: LMP (left mentum posterior) position can lead to cephalopelvic disproportion, making delivery difficult.
A newly pregnant patient tells the nurse that she has irregular periods and is unsure of when she got pregnant. Scheduling an ultrasound is a standing prescription for the patient's health care provider. When is the best time for the nurse to schedule the patient's ultrasound?
- A. Immediately
- B. In 2 weeks
- C. In 4 weeks
- D. In 6 weeks
Correct Answer: A
Rationale: The best time to schedule the ultrasound immediately is because in early pregnancy, it is crucial to confirm the gestational age, rule out ectopic pregnancy, and assess fetal viability. This allows for accurate dating, identification of potential complications, and timely interventions if needed. Waiting for 2, 4, or 6 weeks could delay necessary care and potentially compromise the well-being of the patient and the fetus. Early detection and management of any issues are essential in ensuring a healthy pregnancy outcome.
A nurse is teaching a family about health care plans. Which information from the nurse indicates a correct understanding of the Affordable Care Act?
- A. A family can choose whether to have health insurance with no consequences.
- B. Primary care physician payments from Medicaid services can equal Medicare.
- C. Adult children up to age 26 are allowed coverage on the parent’s plan.
- D. Private insurance companies can deny coverage for any reason.
Correct Answer: C
Rationale: Adult children up to the age of 26, regardless of student status, are allowed to be covered under their parents’ health insurance plan.
The nurse is admitting a client, who reports, 'My water broke yesterday, and I haven't felt my baby move any today.' She is 38 weeks with a history of gestational diabetes. Which assessment data is of most concern to the nurse on admission?
- A. Maternal vital signs: T 100.2, HR 104, RR 20, BP 136/82
- B. Pain score 6/10
- C. Minimal variability and variable decelerations
- D. 5 cm/80% effaced/0 station
Correct Answer: C
Rationale: The correct answer is C because minimal variability and variable decelerations on fetal heart monitoring indicate fetal distress, which is a critical concern. Minimal variability suggests the baby's nervous system is compromised, and decelerations can indicate umbilical cord compression or placental insufficiency, possibly leading to fetal hypoxia. This situation requires immediate intervention to prevent potential harm to the baby.
Choice A is incorrect as the vital signs are slightly elevated but not as concerning as fetal distress. Choice B is incorrect as pain score is subjective and not as critical as fetal well-being. Choice D is incorrect as cervical dilation/effacement/station is important for labor progress but not as concerning as fetal distress in this scenario.