A nurse is caring for a client following an amniocentesis at 18 weeks of gestation. Which of the following findings should the nurse report to the provider as a potential complication?
- A. Increased fetal movement.
- B. Leakage of fluid from the vagina.
- C. Upper abdominal discomfort.
- D. Urinary frequency.
Correct Answer: B
Rationale: The correct answer is B: Leakage of fluid from the vagina. Following an amniocentesis, leakage of fluid from the vagina can indicate a potential complication such as amniotic fluid leakage, which can lead to preterm labor or infection. This finding should be reported to the provider promptly for further evaluation and management. Increased fetal movement (choice A) is a normal occurrence and not typically indicative of a complication. Upper abdominal discomfort (choice C) and urinary frequency (choice D) are common side effects post-amniocentesis and usually resolve without intervention.
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A nurse is preparing to perform Leopold maneuvers for a client. Identify the sequence the nurse should follow. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
- A. Identify the attitude of the head.
- B. Palpate the fundus to identify the fetal part.
- C. Determine the location of the fetal back.
- D. Palpate for the fetal part presenting at the inlet.
Correct Answer: B, C, D, A
Rationale: The correct order for performing Leopold maneuvers is B, C, D, A. Firstly, palpating the fundus (B) helps identify the fetal part. Next, determining the location of the fetal back (C) gives insight into the baby's position. Palpating for the fetal part at the inlet (D) helps determine the presenting part. Finally, identifying the attitude of the head (A) concludes the assessment. The other choices do not align with the sequential nature of Leopold maneuvers, making them incorrect.
A nurse is teaching a postpartum client about steps the nurses will take to promote the security and safety of the client's newborn. Which of the following statements should the nurse make?
- A. "The nurse will carry your baby in their arms to the nursery for scheduled procedures."
- B. "We will document the relationship of visitors in your medical record."
- C. "It's okay for your baby to sleep in the bed with you while in the hospital."
- D. "Staff members who take care of your baby will be wearing a photo identification badge."
Correct Answer: D
Rationale: The correct answer is D. The nurse should inform the client that staff members caring for the newborn will be wearing a photo identification badge as a safety measure. This ensures that only authorized personnel are handling the baby, reducing the risk of abduction or unauthorized access. It also helps the client easily identify legitimate staff members.
Choice A is incorrect because it is not recommended for nurses to carry newborns to the nursery for procedures due to infection control policies. Choice B is irrelevant to promoting the security and safety of the newborn. Choice C is incorrect as bed-sharing with a newborn in the hospital setting is not safe due to the risk of suffocation and Sudden Infant Death Syndrome (SIDS).
Which of the following findings should the nurse report to the provider? Select all that apply.
- A. Respiratory findings
- B. Oxygen saturation
- C. Central nervous system findings
- D. Gastrointestinal findings
Correct Answer: C,D
Rationale: The nurse should report central nervous system (CNS) and gastrointestinal (GI) findings to the provider as they can indicate potential serious issues. CNS findings like altered mental status or neurological deficits may signal neurological problems. GI findings such as abdominal pain or bleeding may indicate gastrointestinal issues that require immediate attention. Respiratory findings (choice A) and oxygen saturation (choice B) are important but may not always require immediate reporting unless they are significantly abnormal. The other choices are not directly related to urgent medical concerns. Reporting CNS and GI findings ensures prompt evaluation and appropriate intervention.
A nurse is performing a routine assessment on a client who is at 18 weeks of gestation. Which of the following findings should the nurse expect?
- A. Deep tendon reflexes 4+.
- B. Fundal height 14 cm.
- C. Blood pressure 142/94 mm Hg.
- D. FHR 152/min.
Correct Answer: D
Rationale: The correct answer is D: FHR 152/min. At 18 weeks gestation, a normal fetal heart rate (FHR) ranges from 120-160/min. This is indicative of a healthy fetus. A: Deep tendon reflexes 4+ is not a typical finding during a routine assessment in pregnancy. B: Fundal height of 14 cm is more consistent with around 12-13 weeks gestation, not 18 weeks. C: Blood pressure of 142/94 mm Hg is elevated and may indicate hypertension, which is not expected at this stage of pregnancy.
A nurse is caring for a client who is in labor and requires augmentation of labor. Which of the following conditions should the nurse recognize as a contraindication to the use of oxytocin?
- A. Post-term with oligohydramnios.
- B. Chorioamnionitis
- C. Shoulder presentation
- D. Diabetes mellitus
Correct Answer: C
Rationale: The correct answer is C: Shoulder presentation. This condition is a contraindication to the use of oxytocin because it can lead to complications such as umbilical cord prolapse, which can be dangerous for both the mother and the baby. Oxytocin can increase the strength and frequency of contractions, potentially worsening the situation.
Choice A: Post-term with oligohydramnios is not a contraindication to the use of oxytocin. It may actually be a reason to consider augmentation of labor.
Choice B: Chorioamnionitis is an infection of the fetal membranes and amniotic fluid, and while it may require treatment, it is not a contraindication to the use of oxytocin.
Choice D: Diabetes mellitus is not a contraindication to the use of oxytocin unless there are specific complications related to diabetes that would make its use risky.
In summary, the correct answer, shoulder presentation,