Nokea
A multigravid client at 34 weeks' gestation visits the hospital because she suspects that her water has broken. After testing the leaking fluid with nitrazine paper, the nurse confirms that the client's membranes have ruptured when the paper turns which of the following colors?
- A. Yellow.
- B. Green.
- C. Blue.
- D. Red.
Correct Answer: C
Rationale: Nitrazine paper turns blue in the presence of amniotic fluid.
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At 38 weeks' gestation, a primigravid client with poorly controlled diabetes and severe preeclampsia is admitted for a cesarean delivery. The nurse explains to the client that delivery helps to prevent which of the following?
- A. Neonatal hyperbilirubinemia.
- B. Congenital anomalies.
- C. Perinatal asphyxia.
- D. Stillbirth.
Correct Answer: D
Rationale: Delivery helps prevent stillbirth in high-risk pregnancies.
A 31-year-old multigravid client at 39 weeks' gestation admitted to the hospital in active labor is receiving intravenous lactated Ringer's solution and a continuous epidural anesthetic. During the first hour after administration of the anesthetic, the nurse should monitor the client for:
- A. Hypotension.
- B. Diaphoresis.
- C. Headache.
- D. Tremors.
Correct Answer: A
Rationale: Epidural anesthesia can cause sympathetic blockade, leading to hypotension, especially within the first hour. Monitoring blood pressure is critical. Diaphoresis, headache, or tremors are less common or less urgent.
Shortly after birth, the nurse measures the circumference of a term neonate's head and chest. When the two measurements are compared, which of the following would the nurse expect to find about the head circumference?
- A. Equal to the chest circumference.
- B. Approximately $2 \mathrm{~cm}$ larger than the chest.
- C. About $3 \mathrm{~cm}$ smaller than the chest.
- D. Approximately $4 \mathrm{~cm}$ larger than the chest.
Correct Answer: B
Rationale: In a term neonate, the head circumference is typically about 2 cm larger than the chest circumference.
A multigravid client at term is admitted to the hospital for a trial labor and possible vaginal birth. She has a history of previous cesarean delivery because of fetal distress. When the client is 4 cm dilated, she receives nalbuphine (Nubain) intravenously. While monitoring the fetal heart rate, the nurse observes minimal variability and a rate of 120 bpm. The nurse should explain the decreased variability is most likely caused by which of the following?
- A. Maternal fatigue.
- B. Fetal malposition.
- C. Small-for-gestational-age fetus.
- D. Effects of analgesic medication.
Correct Answer: D
Rationale: Nalbuphine, an opioid, can reduce fetal heart rate variability by depressing the central nervous system, a common side effect. Maternal fatigue, malposition, or small-for-gestational-age fetus are less likely causes.
A primigravid client with insulin-dependent diabetes tells the nurse that the contraction stress test performed earlier in the day was suspicious. The nurse interprets this test result as indicating that the fetal heart rate pattern showed which of the following?
- A. Frequent late decelerations.
- B. Decreased fetal movement.
- C. Inconsistent late decelerations.
- D. Lack of fetal movement.
Correct Answer: C
Rationale: Suspicious results indicate inconsistent late decelerations.