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A nurse is assessing a client who is in active labor. Which of the following findings should the nurse report to the provider?
- A. Contractions lasting 80 seconds.
- B. Early decelerations in the PHR.
- C. Temperature 37.4° C (99 3* F).
- D. PHR baseline 170/min.
Correct Answer: D
Rationale: A fetal heart rate baseline of 170/min is tachycardic and should be reported to the provider as it may indicate fetal distress.
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Which of the following is a potential ethical issue in maternal and newborn healthcare?
- A. Informed consent
- B. Patient confidentiality
- C. End-of-life decision-making
- D. All of the above
Correct Answer: D
Rationale: The correct answer is D: All of the above. In maternal and newborn healthcare, ethical issues can arise in various aspects such as obtaining informed consent for procedures, ensuring patient confidentiality, and making difficult end-of-life decisions. Informed consent is crucial to respect patient autonomy. Patient confidentiality is vital to maintain trust and privacy. End-of-life decision-making involves complex ethical considerations. Choosing D is correct as all these issues are potential ethical concerns in this specific healthcare context. Choices A, B, and C alone are not comprehensive enough to cover the range of ethical issues that can arise in maternal and newborn healthcare.
What is the primary ethical principle guiding nursing practice in maternal and newborn healthcare?
- A. Autonomy
- B. Non-maleficence
- C. Beneficence
- D. Justice
Correct Answer: C
Rationale: The correct answer is C: Beneficence. In maternal and newborn healthcare, beneficence is the primary ethical principle guiding nursing practice. This principle emphasizes the nurse's duty to promote the well-being and best interests of both the mother and the newborn. Nurses must act in a way that benefits their patients and ensures their safety and health. Autonomy (A) focuses on respecting the patient's right to make their own decisions, which is important but not the primary principle in this context. Non-maleficence (B) involves avoiding harm, which is essential but not the primary guiding principle here. Justice (D) pertains to fairness in healthcare access and resource allocation, which is also crucial but not the primary ethical principle for maternal and newborn healthcare.
A nurse is caring for a client who is at 37 weeks of gestation and is being tested for group B streptococcus ß-hemolytic (GBS). The client is multigravida and multipara with no history of GBS. She asks the nurse why the test was not conducted earlier in her pregnancy. Which of the following is an appropriate response by the nurse?
- A. You didn't report any symptoms of GBS during your pregnancy.'
- B. Your previous deliveries were all negative for GBS.'
- C. There was no indication of GBS in your earlier prenatal testing.'
- D. We need to know if you are positive for GBS at the time of delivery.'
Correct Answer: D
Rationale: The correct answer is D: "We need to know if you are positive for GBS at the time of delivery." This response is appropriate because GBS status can change throughout pregnancy, and testing closer to delivery provides the most accurate information to guide treatment and prevent transmission to the newborn.
Choice A is incorrect as GBS is often asymptomatic and can be present without any noticeable symptoms. Choice B is incorrect because GBS status can change between pregnancies. Choice C is incorrect as GBS testing at 37 weeks is standard practice regardless of earlier prenatal testing results.
Which stage of labor is characterized by the delivery of the placenta?
- A. First stage
- B. Second stage
- C. Third stage
- D. Fourth stage
Correct Answer: C
Rationale: The correct answer is C: Third stage. This stage is characterized by the delivery of the placenta. It occurs after the baby is born (second stage) and involves the detachment and expulsion of the placenta from the uterus. The first stage is characterized by cervical dilation and effacement, while the fourth stage is the immediate postpartum period. The second stage is focused on the actual birth of the baby. Therefore, the delivery of the placenta specifically occurs in the third stage of labor.
Select the 5 actions the nurse should take
- A. Increase the flow rate of the maintenance IV fuid
- B. Have the charge nurse notify the provider
- C. Place the client in a Trendelenburg position
- D. Exert upward pressure on the presenting part.
- E. Attempt to push the umbilical cord back into the cervix
- F. Administer oxygen at 10 L/mm via nonrebreather face mask
Correct Answer: A,B,C,D,F
Rationale: A prolapsed umbilical cord is a life-threatening emergency requiring immediate intervention to relieve cord compression and restore fetal oxygenation. The priority actions are:
Notify the provider
Reposition the client (Trendelenburg or knee-chest)
Manually relieve pressure on the cord
Administer oxygen
Increase IV fluids for better circulation