Nokea
A nurse is caring for a client who is at 37 weeks of gestation and is being tested for group B streptococcus ß-hemolytic (GBS). The client is multigravida and multipara with no history of GBS. She asks the nurse why the test was not conducted earlier in her pregnancy. Which of the following is an appropriate response by the nurse?
- A. You didn't report any symptoms of GBS during your pregnancy.'
- B. Your previous deliveries were all negative for GBS.'
- C. There was no indication of GBS in your earlier prenatal testing.'
- D. We need to know if you are positive for GBS at the time of delivery.'
Correct Answer: D
Rationale: Rationale: Answer D is correct because testing for GBS at 37 weeks ensures detection of any recent colonization, which can change rapidly. Testing earlier in pregnancy may not accurately reflect GBS status at the time of delivery. Answers A, B, and C are incorrect because the focus should be on current GBS status, not past symptoms or test results. The nurse should prioritize testing closer to delivery for accurate results.
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A nurse is assessing a newborn who was born postterm. Which of the following findings should the nurse expect?
- A. Large deposits of subcutaneous fat
- B. Thin covering of fine hair on shoulders and back
- C. Nails extending over tips of fingers
- D. Pale, translucent skin
Correct Answer: C
Rationale: The correct answer is C: Nails extending over tips of fingers. Postterm newborns have longer nails due to their prolonged growth in utero. This is a common finding in babies born after 42 weeks gestation. Large deposits of subcutaneous fat (choice A) are typically seen in term or postterm newborns, not specific to postterm. Thin covering of fine hair on shoulders and back (choice B) is known as lanugo, which is present in premature infants, not postterm. Pale, translucent skin (choice D) is more common in premature infants, not postterm.
A nurse is caring for a client who is 1 hr postpartum and has uterine atony. The client is exhibiting a large amount of vaginal bleeding. Which of the following actions should the nurse take?
- A. Administer betamethasone IM.
- B. Avoid performing sterile vaginal examinations.
- C. Anticipate a prescription for misoprostol.
- D. Obtain a specimen for a Kleihauer-Betke test.
Correct Answer: C
Rationale: Correct Answer: C. Anticipate a prescription for misoprostol.
Rationale: Misoprostol is a medication that helps to induce uterine contractions, which can help control postpartum bleeding due to uterine atony. It is a common pharmacological intervention for this situation.
Incorrect Choices:
A: Administering betamethasone IM is not indicated for postpartum hemorrhage due to uterine atony. This medication is typically used for fetal lung maturation in preterm labor.
B: Avoiding performing sterile vaginal examinations does not address the primary concern of uterine atony and postpartum bleeding. Assessing the uterus and bleeding are crucial in this situation.
D: Obtaining a specimen for a Kleihauer-Betke test is used to determine the amount of fetal-maternal hemorrhage in Rh-negative women. While important in some situations, it is not the priority in managing postpartum hemorrhage.
A nurse is caring for a client immediately following the delivery of a stillborn fetus. Which of the following actions should the nurse take?
- A. Limit the amount of time the fetus is in the client’s room.
- B. Provide the client with photos of the fetus.
- C. Instruct the client that an autopsy should be performed within 24 hr.
- D. Inform the client that the law requires them to name the fetus.
Correct Answer: B
Rationale: The correct answer is B: Provide the client with photos of the fetus. This action allows the client to have tangible memories of their stillborn child, which can aid in the grieving process and provide closure. Providing photos is a sensitive and compassionate gesture that acknowledges the significance of the loss. It also respects the client's autonomy in choosing how they wish to remember their child.
The other choices are not appropriate in this situation:
A: Limiting the time the fetus is in the room may not consider the emotional needs of the client.
C: Instructing the client about an autopsy may be insensitive and distressing without discussing it first with the client.
D: Informing the client about naming the fetus is not a legal requirement and could add unnecessary pressure during a difficult time.
A nurse is providing prenatal teaching to a client who practices a vegan diet and is trying to increase intake of vitamin B12. Which of the following foods should the nurse recommend?
- A. Fortified soy milk
- B. Raw carrots
- C. Fresh citrus fruits
- D. Brown rice
Correct Answer: A
Rationale: The correct answer is A: Fortified soy milk. Soy milk is often fortified with vitamin B12, making it a suitable option for a client following a vegan diet. Vitamin B12 is primarily found in animal products, so vegans need to ensure they get an adequate intake from fortified foods or supplements. Raw carrots (B), fresh citrus fruits (C), and brown rice (D) do not contain significant amounts of vitamin B12 and would not be effective in increasing intake. A detailed explanation is crucial in guiding the client to make informed choices for their dietary needs.
A nurse is caring for a client who is receiving oxytocin via continuous IV infusion and is experiencing persistent late decelerations in the FHR. After discontinuing the infusion, which of the following actions should the nurse take?
- A. Instruct the client to bear down and push with contractions.
- B. Administer oxygen at 10 L/min via nonrebreather facemask.
- C. Place the client in a supine position.
- D. Initiate an amnioinfusion.
Correct Answer: B
Rationale: The correct answer is B: Administer oxygen at 10 L/min via nonrebreather facemask. Late decelerations in fetal heart rate (FHR) indicate uteroplacental insufficiency, possibly due to decreased oxygen supply to the fetus. Providing oxygen to the mother increases oxygen delivery to the fetus, improving oxygenation and potentially reversing the late decelerations. Other choices are incorrect: A could increase intra-abdominal pressure, worsening late decelerations. C can decrease placental perfusion. D is not indicated for late decelerations.