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A nurse in a provider’s office is caring for a 20-year-old client who is at 12 weeks of gestation and requests an amniocentesis to determine the sex of the fetus. Which of the following responses should the nurse make?
- A. You cannot have an amniocentesis until you are at least 35 years of age.
- B. This procedure determines if your baby has genetic or congenital disorders.
- C. Your provider will schedule a chorionic villus sampling to determine the sex of your baby.
- D. We can schedule the procedure for later today if you’d like.
Correct Answer: B
Rationale: The correct answer is B: This procedure determines if your baby has genetic or congenital disorders. At 12 weeks of gestation, amniocentesis is typically not done to determine the sex of the fetus but rather to identify genetic abnormalities or congenital disorders. Providing this information allows the client to make informed decisions about their pregnancy and potential interventions.
A: You cannot have an amniocentesis until you are at least 35 years of age - This statement is incorrect as age alone is not the sole criteria for recommending amniocentesis.
C: Your provider will schedule a chorionic villus sampling to determine the sex of your baby - Chorionic villus sampling is also not typically done to determine the sex of the fetus.
D: We can schedule the procedure for later today if you’d like - This is incorrect as scheduling an amniocentesis without a medical indication is not appropriate.
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A nurse is preparing to perform Leopold maneuvers on a client who is at 36 weeks of gestation. Identify the sequence of actions the nurse should take.
- A. Instruct the client to empty their bladder.
- B. Position the client supine with knees flexed and place a small, rolled towel under one of their hips.
- C. Palpate the fetal part positioned in the fundus.
- D. Palpate the fetal parts along both sides of the uterus.
Correct Answer: A, B, C, D
Rationale: The correct sequence for performing Leopold maneuvers is A, B, C, D. Firstly, instructing the client to empty their bladder (A) allows for better visualization and palpation of the fetus. Positioning the client supine with knees flexed and a rolled towel under one hip (B) helps relax the abdomen and facilitate palpation. Palpating the fetal part in the fundus (C) helps determine the fetal presentation and position. Finally, palpating the fetal parts along both sides of the uterus (D) aids in assessing the fetal lie and engagement. Choices E, F, and G are not relevant to the correct sequence of Leopold maneuvers.
A nurse is caring for a client who is in active labor with a fetus in the occipitoposterior position. The nurse assists the client into a hands-and-knees position. Which of the following questions should the nurse ask to evaluate the effectiveness of this intervention?
- A. Does that lessen your suprapubic pain?
- B. Are you feeling relief from your pelvic pressure?
- C. Do your contractions feel further apart?
- D. Has your back labor improved?
Correct Answer: D
Rationale: The correct answer is D: "Has your back labor improved?" This question is crucial because the occipitoposterior position can cause intense back pain during labor. By asking if the back labor has improved, the nurse can assess the effectiveness of the hands-and-knees position in helping relieve the client's discomfort. A: "Does that lessen your suprapubic pain?" is incorrect because suprapubic pain is not specifically associated with occipitoposterior positioning. B: "Are you feeling relief from your pelvic pressure?" is incorrect as it does not directly address the back pain associated with occipitoposterior positioning. C: "Do your contractions feel further apart?" is incorrect as it does not focus on the back pain issue. The key is to address the specific discomfort caused by the occipitoposterior position.
A nurse is assessing a client who is postpartum following a cesarean birth. The client states, 'I feel like I have to urinate but I can’t go.' Which of the following actions should the nurse take?
- A. Assist the client to ambulate to the bathroom
- B. Insert an indwelling urinary catheter
- C. Perform a bladder scan to assess for urinary retention
- D. Administer a diuretic
Correct Answer: A
Rationale: Correct Answer: A. Assist the client to ambulate to the bathroom.
Rationale: By assisting the client to ambulate to the bathroom, the nurse is promoting normal physiological functioning. Walking can help stimulate the bladder and promote urination, which is often needed after a cesarean birth due to the effects of anesthesia and limited mobility. It also helps prevent complications like urinary retention or urinary tract infections. Encouraging the client to move also aids in promoting circulation, preventing blood clots, and enhancing overall recovery.
Summary of other choices:
B: Inserting an indwelling catheter should not be the first intervention as it can increase the risk of infection and discomfort.
C: Performing a bladder scan is not necessary as the client's symptoms do not indicate a need for immediate assessment of urine volume.
D: Administering a diuretic is not appropriate without assessing the client's condition further as it may not address the underlying issue and could exacerbate any existing problems.
Which of the following findings should the nurse report to the provider?Select the 3 findings that should be reported.
- A. Uterine contractions
- B. Fetal heart rate
- C. Gestational age
- D. Vaginal examination
- E. Maternal blood pressure
Correct Answer: A,B,D
Rationale: The correct answers to report to the provider are A, B, and D.
A: Uterine contractions - Significant contractions could indicate preterm labor.
B: Fetal heart rate - Abnormal fetal heart rate can indicate fetal distress.
D: Vaginal examination - Risk of infection or cervical changes need provider evaluation.
C: Gestational age - Routine information, not typically requiring immediate provider notification.
E: Maternal blood pressure - Important but not typically urgent unless severely abnormal.
A nurse is caring for a client who is receiving oxytocin via continuous IV infusion and is experiencing persistent late decelerations in the FHR. After discontinuing the infusion, which of the following actions should the nurse take?
- A. Instruct the client to bear down and push with contractions.
- B. Administer oxygen at 10 L/min via nonrebreather facemask.
- C. Place the client in a supine position.
- D. Initiate an amnioinfusion.
Correct Answer: B
Rationale: The correct answer is B: Administer oxygen at 10 L/min via nonrebreather facemask. Late decelerations in the fetal heart rate (FHR) indicate uteroplacental insufficiency, which could lead to fetal hypoxia. Providing oxygen at 10 L/min via a nonrebreather facemask helps improve oxygenation for both the mother and the fetus. This intervention aims to increase oxygen delivery to the placenta and subsequently improve fetal oxygenation. In contrast, option A (instructing the client to bear down and push with contractions) can further compromise fetal oxygenation. Option C (placing the client in a supine position) can worsen uteroplacental perfusion. Option D (initiating an amnioinfusion) is not indicated for late decelerations and does not address the underlying cause of fetal hypoxia.