Nokea
A nurse is assessing the fetal heart rate of a laboring person. What is the most significant finding that would indicate fetal distress?
- A. variable decelerations
- B. late decelerations
- C. bradycardia
- D. accelerations
Correct Answer: C
Rationale: The correct answer is C, bradycardia. Bradycardia in the fetal heart rate is a significant finding indicating fetal distress because it signifies a heart rate below normal range, which can lead to inadequate oxygen supply to the fetus. Bradycardia can be a sign of fetal hypoxia, acidosis, or other serious conditions. Variable decelerations (choice A) are often caused by umbilical cord compression, late decelerations (choice B) are associated with uteroplacental insufficiency, and accelerations (choice D) are considered a reassuring sign of fetal well-being. Therefore, in the context of fetal distress, bradycardia is the most concerning finding.
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Place these developmental milestones in chronological order: Four-chambered heart forms, Vernix caseosa appears, Blastocyst development completes, Testes descend
- A. Blastocyst development complete
- B. Four-chambered heart forms
- C. Vernix caseosa present
- D. Testes descend into scrotum
Correct Answer: B
Rationale: Development follows the sequence: blastocyst formation, four-chambered heart, vernix appearance, and testicular descent.
The nurse is caring for a pregnant patient who is 24 weeks gestation and has been diagnosed with a urinary tract infection (UTI). Which of the following interventions should the nurse prioritize?
- A. Administer antibiotics as prescribed.
- B. Encourage the patient to drink cranberry juice.
- C. Provide education about the signs of preterm labor.
- D. Schedule a follow-up ultrasound to assess fetal health.
Correct Answer: A
Rationale: The correct answer is A: Administer antibiotics as prescribed. The priority is to treat the UTI to prevent potential harm to the patient and fetus. Antibiotics are necessary to eliminate the infection and reduce the risk of complications. Encouraging cranberry juice (B) may be beneficial for prevention but is not sufficient to treat an existing UTI. Providing education about preterm labor signs (C) is important but addressing the infection is the immediate concern. Scheduling a follow-up ultrasound (D) may be necessary later but does not address the urgent need to treat the UTI.
A laboring person requests an epidural for pain relief. What is the nurse's priority action before the procedure?
- A. administer a test dose of anesthesia
- B. ensure informed consent is obtained
- C. administer IV fluids
- D. ensure continuous fetal monitoring
Correct Answer: A
Rationale: The correct answer is A: administer a test dose of anesthesia. Before administering an epidural, it is crucial to perform a test dose to assess the person's response and ensure correct placement of the catheter. This step helps prevent potential complications such as unintentional intravascular injection.
Summary:
B: Ensuring informed consent is important but not the priority before administering the test dose.
C: Administering IV fluids is important for hydration but not the immediate priority before the test dose.
D: Continuous fetal monitoring is essential during labor, but it is not the priority before administering the test dose of anesthesia.
A nurse is caring for a pregnant patient who is 24 weeks gestation and has been diagnosed with anemia. What should the nurse teach the patient about managing this condition?
- A. Increase iron-rich foods and take iron supplements as prescribed.
- B. Rest frequently and avoid physical activity to prevent exhaustion.
- C. Limit intake of dairy products to prevent iron deficiency.
- D. Incorporate more vitamin D-rich foods into the diet to help the body absorb iron.
Correct Answer: A
Rationale: The correct answer is A because increasing iron-rich foods and taking iron supplements as prescribed is the standard treatment for managing anemia during pregnancy. Iron is essential for red blood cell production, which is crucial for both the mother and the developing fetus. Resting frequently (choice B) may help with fatigue but does not address the root cause of anemia. Limiting dairy intake (choice C) is not necessary and may lead to other nutritional deficiencies. Incorporating vitamin D-rich foods (choice D) can be beneficial for overall health but does not specifically address the management of anemia.
Which is fetal tachycardia likely caused by?
- A. Compression of the umbilical cord
- B. Maternal infection
- C. Compression of the fetal head
- D. Maternal hypertension
Correct Answer: B
Rationale: The correct answer is B: Maternal infection. Maternal infection can lead to fetal tachycardia due to the transfer of inflammatory mediators from the mother to the fetus, causing an increase in the fetal heart rate. This physiological response is a common indicator of fetal distress in utero.
A: Compression of the umbilical cord can lead to fetal distress, but it typically manifests as bradycardia rather than tachycardia.
C: Compression of the fetal head can cause fetal distress, but it is more likely to result in decelerations in heart rate rather than tachycardia.
D: Maternal hypertension can lead to complications during pregnancy, but it is not typically associated with fetal tachycardia.