Maternal Monitoring

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A nurse is assessing a laboring person for signs of fetal distress. What is the most common sign of fetal distress?

  • A. increase oxygen flow
  • B. tachycardia
  • C. bradycardia
  • D. irregular fetal heart rate
Correct Answer: B

Rationale: The correct answer is B: tachycardia. Fetal distress is often indicated by an increased fetal heart rate, known as tachycardia. This can be a sign of the fetus not receiving enough oxygen. Bradycardia (choice C) is a lower heart rate and not typically associated with fetal distress. Irregular fetal heart rate (choice D) may also indicate distress, but tachycardia is more commonly observed. Increasing oxygen flow (choice A) is a potential intervention for fetal distress but not a sign of distress itself. In summary, tachycardia is the most common sign of fetal distress due to potential oxygen deprivation.

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A nurse is advising a pregnant woman about the danger signs of pregnancy. The nurse should teach the mother that she should notify the physician immediately if she experiences which of the following signs/symptoms? Select all that apply.

  • A. Convulsions.
  • B. Double vision.
  • C. Epigastric pain.
  • D. Persistent vomiting.
Correct Answer: D

Rationale: These symptoms may indicate severe complications such as preeclampsia, eclampsia, or hyperemesis gravidarum, requiring immediate medical attention. Polyuria is generally not a danger sign.

A gravid woman who recently emigrated from mainland China is being seen at her first prenatal visit. She was never vaccinated in her home country. An injection to prevent which of the following communicable diseases should be administered to the woman during her pregnancy?

  • A. Influenza.
  • B. Mumps.
  • C. Rubella.
  • D. Varicella.
Correct Answer: A

Rationale: Influenza vaccination is safe and recommended during pregnancy to protect both the mother and fetus. Vaccines for Mumps, Rubella, and Varicella are live attenuated vaccines and are contraindicated during pregnancy.

The nurse notes each of the following findings in a 10-week gestation client. Which of the findings would enable the nurse to tell the client that she is positively pregnant?

  • A. Fetal heart rate via Doppler.
  • B. Positive pregnancy test.
  • C. Positive Chadwick’s sign.
  • D. Montgomery gland enlargements.
Correct Answer: A

Rationale: A fetal heart rate detected via Doppler is a positive sign of pregnancy. A positive pregnancy test, Chadwick’s sign, and Montgomery gland enlargements are probable signs but not definitive.

What fetal change occurs when the fundal height reaches the xiphoid process?

  • A. Surfactant forms in lungs
  • B. Eyes begin to open and close
  • C. Respiratory movements begin
  • D. Spinal column is complete
Correct Answer: A

Rationale: Surfactant production begins in the lungs around this stage of pregnancy, preparing them for postnatal breathing.

What is the purpose of amniocentesis for a patient hospitalized at 34 weeks of gestation with pregnancy-induced hypertension?

  • A. Determine if a metabolic disorder exists.
  • B. Identify the sex of the fetus.
  • C. Identify abnormal fetal cells.
  • D. Determine fetal lung maturity.
Correct Answer: D

Rationale: At 34 weeks, amniocentesis is primarily used to assess fetal lung maturity, which is critical if early delivery is being considered.

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