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A nurse is assisting with a vaginal birth and is monitoring for signs of placental separation. What is the most reliable clinical indicator that the placenta has separated?
- A. a gush of clear amniotic fluid
- B. uterine contractions every 2 to 3 minutes
- C. lengthening of the umbilical cord
- D. maternal report of intense pain
Correct Answer: C
Rationale: The correct answer is C: lengthening of the umbilical cord. This is the most reliable indicator of placental separation because as the placenta detaches from the uterine wall, the cord lengthens as it moves downward. This signifies that the placenta has separated completely.
A: A gush of clear amniotic fluid is not a reliable indicator of placental separation as it can occur before or after placental separation.
B: Uterine contractions every 2 to 3 minutes are a sign of labor progression, not specifically placental separation.
D: Maternal report of intense pain can be subjective and may not always indicate placental separation.
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A nurse is assessing a laboring person who is receiving oxytocin for labor induction. What is the most important intervention to prevent uterine hyperstimulation?
- A. monitor fetal heart rate
- B. increase fetal monitoring
- C. administer an epidural
- D. monitor contractions
Correct Answer: B
Rationale: The correct answer is B: increase fetal monitoring. Monitoring the fetus closely is crucial to detect signs of uterine hyperstimulation, such as non-reassuring fetal heart rate patterns. This allows for timely interventions to prevent fetal distress or hypoxia. Monitoring contractions (choice D) is important but does not directly address fetal well-being. Administering an epidural (choice C) may help manage pain but does not prevent uterine hyperstimulation. While monitoring fetal heart rate (choice A) is important, increasing the frequency of monitoring (choice B) is more specific to detecting complications related to oxytocin-induced uterine hyperstimulation.
Why is pregnancy planning important for women of childbearing age?
- A. Much organogenesis occurs before the missed period
- B. Insurance preapproval is required
- C. No more than 3 pregnancies are recommended
- D. Pregnancies less than 2 years apart stress the cardiovascular system
Correct Answer: A
Rationale: Organogenesis occurs early in pregnancy, often before a missed period, making early intervention critical for fetal health.
For which patient would an L/S ratio of 2:1 potentially be considered abnormal?
- A. A 38-year-old gravida 2, para 1, who is 38 weeks’ gestation
- B. A 24-year-old gravida 1, para 0, who has diabetes
- C. A 44-year-old gravida 6, para 5, who is at term
- D. An 18-year-old gravida 1, para 0, who is in early labor at term
Correct Answer: B
Rationale: In diabetic pregnancies, an L/S ratio of 2:1 may not reliably indicate lung maturity due to delayed surfactant production.
A nurse is caring for a 38-week pregnant patient who is experiencing a decrease in fetal movement. Which of the following should be the nurse's first action?
- A. Encourage the patient to drink a cold beverage and lie down.
- B. Instruct the patient to wait 24 hours and monitor fetal movements.
- C. Order an ultrasound to check the baby's health.
- D. Call the healthcare provider immediately to report the decrease in movement.
Correct Answer: A
Rationale: The correct answer is A: Encourage the patient to drink a cold beverage and lie down. This is the correct action as it promotes fetal movement by stimulating the baby with a change in temperature and position. It is a non-invasive and immediate measure that can be taken by the patient herself.
Choice B is incorrect because waiting 24 hours could delay necessary intervention if the fetus is in distress. Choice C is incorrect as ordering an ultrasound may not be the most immediate or necessary action at this point. Choice D is incorrect as calling the healthcare provider immediately may not be necessary if the issue can be resolved by the patient changing her position and trying to stimulate fetal movement first.
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.