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A nurse in an antepartum clinic is providing weeks of gestation. Upon reviewing the following findings should the nurse report to the provider? (Click on the 'Exhibit' button for additional information about the client. There are three tabs that contain separate categories of data.)
- A. 1-hr glucose tolerance test
- B. Hematocrit
- C. Fundal height measurement
- D. Fetal heart rate (FHR)
Correct Answer: D
Rationale: The correct answer is D: Fetal heart rate (FHR). The nurse should report any abnormal findings related to fetal well-being to the provider. Monitoring the FHR is crucial to assess the baby's status and can indicate potential issues such as fetal distress. In this scenario, if the FHR is abnormal (e.g., too high or too low), it could signal a problem that needs immediate attention.
A: 1-hr glucose tolerance test - This is typically done to screen for gestational diabetes and is not directly related to fetal well-being.
B: Hematocrit - This measures the volume percentage of red blood cells in blood and is more related to maternal health.
C: Fundal height measurement - This assesses fetal growth and position, but abnormal findings may not require immediate provider notification unless significant deviations are noted.
In summary, the other choices are not as time-sensitive or directly indicative of fetal distress as the FHR, making D the correct answer in this context.
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A nurse is assessing a late preterm newborn. Which of the following manifestations is an indication of hypoglycemia?
- A. Hypertonia.
- B. Increased feeding.
- C. Hyperthermia.
- D. Respiratory distress.
Correct Answer: D
Rationale: The correct answer is D: Respiratory distress. Hypoglycemia in a late preterm newborn can lead to respiratory distress due to decreased glucose levels affecting cellular function and energy production. Hypertonia (choice A) is not typically associated with hypoglycemia in newborns. Increased feeding (choice B) may be a response to hypoglycemia but is not a direct manifestation. Hyperthermia (choice C) is not a common sign of hypoglycemia. Therefore, the correct choice is D as it directly reflects the impact of low glucose levels on respiratory function.
A nurse is teaching a client who is at 10 weeks of gestation about nutrition during pregnancy. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should increase my protein intake to 60 grams each day.
- B. I should drink 2 liters of water each day.
- C. I should increase my overall daily caloric intake by 300 calories.
- D. I should take 600 micrograms of folic acid each day.
Correct Answer: D
Rationale: The correct answer is D because folic acid is crucial during pregnancy to prevent birth defects like spina bifida. It is recommended to take 600 micrograms daily. Choice A is incorrect as the recommended protein intake is 71 grams/day. Choice B is important but doesn't address nutrition specifically. Choice C is unnecessary and could lead to excessive weight gain.
A nurse is caring for a client who is at 38 weeks of gestation. Which of the following actions should the nurse take prior to applying an external transducer for fetal monitoring?
- A. Determine progression of dilatation and effacement.
- B. Perform Leopold maneuvers.
- C. Complete a sterile speculum exam.
- D. Prepare a Nitrazine paper test.
Correct Answer: B
Rationale: The correct answer is B: Perform Leopold maneuvers. Prior to applying an external transducer for fetal monitoring, the nurse should perform Leopold maneuvers to assess the fetal position, presentation, lie, and engagement. This helps in determining the optimal placement of the transducer for accurate monitoring of the fetal heart rate. It allows the nurse to locate the fetal back and position the transducer over the fetal heart for the best signal quality.
Choices A, C, and D are incorrect:
A: Determining progression of dilatation and effacement is not necessary before applying the external transducer.
C: Completing a sterile speculum exam is not needed for fetal monitoring.
D: Preparing a Nitrazine paper test is unrelated to applying an external transducer.
A nurse is caring for a client who is at 10 weeks of gestation. Which of the following findings should the nurse report to the provider?
- A. Frequent vomiting with weight loss of 3 lb in 1 week.
- B. Reports of mood swings.
- C. Nosebleeds occurring approximately 3 times per week.
- D. Increased vaginal discharge.
Correct Answer: A
Rationale: The correct answer is A. Frequent vomiting with weight loss of 3 lb in 1 week can indicate hyperemesis gravidarum, a severe form of nausea and vomiting during pregnancy that can lead to dehydration and electrolyte imbalances. This finding is concerning and requires immediate medical attention to prevent complications. Reporting this to the provider allows for timely intervention.
Other choices are incorrect:
B: Reports of mood swings are common during pregnancy due to hormonal changes and are not typically a cause for immediate concern.
C: Nosebleeds occurring approximately 3 times per week can be due to increased blood flow during pregnancy and are usually not a significant concern unless severe or persistent.
D: Increased vaginal discharge is a common symptom in early pregnancy due to hormonal changes and increased blood flow to the pelvic area. It is not typically an urgent issue unless accompanied by other symptoms like itching or foul odor.
A nurse is caring for a newborn who was transferred to the nursery 30 min after birth because of mild respiratory distress. Which of the following actions should the nurse take first?
- A. Confirm the newborn's Apgar score.
- B. Verify the newborn's identification.
- C. Administer vitamin K to the newborn.
- D. Determine obstetrical risk factors.
Correct Answer: B
Rationale: The correct answer is B: Verify the newborn's identification. This should be done first to ensure the right baby is receiving care. Confirming the identity helps prevent errors in medication administration and procedures. Checking the identification is crucial for patient safety. The other options are not the first priority in this scenario. A: Confirming the Apgar score can wait until after ensuring the correct baby is being cared for. C: Administering vitamin K is important, but verifying identification takes precedence. D: Determining obstetrical risk factors can be done later once the baby's identity is confirmed.