Nokea
A nurse is assessing a client who is at 31 weeks of gestation. Which of the following findings should the nurse identify as an indication of a potential prenatal complication?
- A. Periodic tingling of fingers
- B. Absence of clonus
- C. Leg cramps
- D. Blurred vision
Correct Answer: D
Rationale: Blurred vision can be an indicator of serious conditions such as preeclampsia, which involves hypertension and can lead to significant maternal and fetal complications.
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A nurse is caring for a laboring client and notes that the fetal heart rate begins to decelerate after the contraction has started. The lowest point of deceleration occurs after the peak of the contraction. What is the priority nursing action?
- A. Administer oxygen
- B. Change the client's position
- C. Increase IV fluids
- D. Call the healthcare provider
Correct Answer: B
Rationale: Late decelerations are caused by uteroplacental insufficiency, indicating that the fetus is not receiving adequate oxygen during contractions. This is an emergency that requires prompt intervention. Changing the client's position helps to improve placental blood flow, which can reduce the stress on the fetus. If the decelerations continue, further interventions, including oxygen administration and notifying the provider, may be necessary.
A nurse is caring for a client who is receiving magnesium sulfate for preeclampsia. Which of the following findings should the nurse report to the healthcare provider?
- A. Urinary output of 40 mL/hr
- B. Respiratory rate of 10 breaths per minute
- C. Absent deep tendon reflexes
- D. Blood pressure of 150/90 mm Hg
Correct Answer: B
Rationale: Magnesium sulfate can depress the central nervous system, leading to respiratory depression. A respiratory rate of 10 breaths per minute is below the normal range and requires immediate intervention.
A nurse is performing a newborn assessment and notes a soft, swollen area on the newborn's scalp that does not cross the suture line. Which of the following should the nurse document?
- A. Cephalohematoma
- B. Caput succedaneum
- C. Subdural hematoma
- D. Molding
Correct Answer: A
Rationale: A cephalohematoma is a collection of blood between the periosteum and the skull that does not cross the suture line. It results from trauma during birth and typically resolves on its own.
A nurse is caring for a newborn who is 1 hour old and has a respiratory rate of 50 breaths per minute with periods of apnea lasting up to 10 seconds. Which of the following actions should the nurse take?
- A. Administer oxygen
- B. Stimulate the newborn
- C. Initiate positive pressure ventilation
- D. Continue routine monitoring
Correct Answer: D
Rationale: A respiratory rate of 50 breaths per minute with occasional periods of apnea lasting less than 15 seconds is normal for a newborn. The nurse should continue routine monitoring unless the apneic periods become prolonged or the newborn shows signs of respiratory distress.
A nurse is providing education to a client who is 28 weeks pregnant and at risk for preterm labor. Which of the following signs should the nurse instruct the client to report immediately?
- A. Lower back pain
- B. Shortness of breath
- C. Decreased fetal movement
- D. Nausea and vomiting
Correct Answer: A
Rationale: Lower back pain, especially if accompanied by uterine contractions or pressure, can be a sign of preterm labor. The client should report this immediately to prevent complications or early delivery.