Nokea
A nurse is assessing the results of a nonstress test for an antepartum client at 35 weeks of gestation. Which of the following findings should indicate to the nurse the need for further diagnostic testing?
- A. Three fetal movements perceived by the client in a 20 min testing period
- B. No late decelerations in the fetal heart rate noted with three uterine contractions of 60 seconds in duration within a 10-min resting period
- C. An increase in fetal heart rate to 150/min above the baseline of 140/min lasting 10 seconds in response to fetal movement within a 40-min testing period
- D. Irregular contractions of 10 to 20 seconds in duration that are not felt by the client
Correct Answer: A
Rationale: Only three fetal movements in 20 minutes is below the expected activity level, suggesting possible fetal compromise, unlike reassuring heart rate responses or minor contractions.
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A nurse manager on the labor and delivery unit is teaching a group of newly licensed nurses about maternal cytomegalovirus. Which of the following information should the nurse manager include in the teaching?
- A. Transmission can occur via the saliva and urine of the newborn
- B. This infection requires that airborne precautions be initiated for the newborn
- C. Mothers will receive prophylactic treatment with acyclovir prior to delivery
- D. Lesions are visible on the mother's genitalia
Correct Answer: A
Rationale: CMV transmission occurs through newborn saliva and urine, unlike requiring airborne precautions, acyclovir (herpes treatment), or visible genital lesions (not typical).
A nurse is providing teaching to a client who is primigravid and is scheduled to have an abdominal ultrasound. Which of the following statements by the client indicates an understanding of the teaching?
- A. I won't apply perfumed lotion to my abdomen before the test.
- B. I can't have anything to eat after midnight.
- C. I need to take a stool softener the night before the test.
- D. I will drink water before the test until my bladder feels full.
Correct Answer: D
Rationale: A full bladder enhances ultrasound visibility by displacing intestines, unlike avoiding lotion, fasting, or stool softeners, which are not required.
A nurse is planning care for a client who is pregnant and has HIV. Which of the following actions should the nurse include in the plan of care?
- A. Instruct the client to stop taking the antiretroviral medications at 32 weeks of gestation.
- B. Use a fetal scalp electrode during labor and delivery.
- C. Bathe the newborn before initiating skin-to-skin contact.
- D. Administer a pneumococcal immunization to the newborn within 4 hr following birth.
Correct Answer: C
Rationale: Bathing the newborn removes maternal fluids, reducing HIV transmission risk, unlike stopping antiretrovirals (continued), scalp electrodes (increase risk), or pneumococcal vaccine (not routine).
A nurse is caring for a client who is at 30 weeks of gestation and receiving magnesium sulfate for preeclampsia. The nurse should recognize which of the following manifestations is an adverse reaction to the medication?
- A. Hypertension
- B. Hypoglycemia
- C. Respiratory rate 16/min
- D. Urine output 20 mL/hr
Correct Answer: D
Rationale: Urine output of 20 mL/hr suggests oliguria, risking magnesium toxicity due to poor renal excretion, unlike hypertension (preeclampsia symptom), hypoglycemia (unrelated), or normal respiratory rate.
A nurse is reviewing the chart of a client who is 2 days postpartum following a vaginal delivery and reports constipation. Which of the following findings should the nurse identify as a contraindication to the use of a suppository?
- A. Abdominal distention
- B. Third-degree perineal laceration
- C. Vaginal candidiasis
- D. Afterpain
Correct Answer: B
Rationale: A third-degree perineal laceration contraindicates suppositories to avoid further trauma and delayed healing, unlike distention, candidiasis, or afterpain, which are not contraindications.