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A nurse is caring for a client who is at 41 weeks of gestation and has a positive contraction stress test. For which of the following diagnostic tests should the nurse prepare the client?
- A. Percutaneous umbilical blood sampling.
- B. Amnioinfusion.
- C. Biophysical profile (BPP).
- D. Chorionic villus sampling (CVS).
Correct Answer: C
Rationale: The correct answer is C: Biophysical profile (BPP). At 41 weeks gestation with a positive contraction stress test, the client may be at risk for uteroplacental insufficiency. A BPP assesses fetal well-being by evaluating fetal movement, tone, breathing, amniotic fluid volume, and fetal heart rate reactivity. This test helps determine if the fetus is getting enough oxygen and nutrients. Preparing the client for a BPP is crucial in monitoring the fetal status and making decisions regarding further management.
Incorrect choices:
A: Percutaneous umbilical blood sampling is an invasive procedure used to evaluate fetal blood gases and acid-base status, typically performed when there are concerns about fetal well-being like severe growth restriction or Rh incompatibility.
B: Amnioinfusion is the infusion of fluid into the amniotic cavity and is used to correct oligohydramnios (low amniotic fluid volume).
D: Chorionic villus
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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.
A nurse is assessing a client who is postpartum and has idiopathic thrombocytopenia purpura (ITP). Which of the following findings should the nurse expect?
- A. Decreased platelet count.
- B. Increased erythrocyte sedimentation rate (ESR).
- C. Decreased megakaryocytes.
- D. Increased WBC.
Correct Answer: A
Rationale: The correct answer is A: Decreased platelet count. In idiopathic thrombocytopenia purpura (ITP), there is a decrease in platelet count due to immune-mediated destruction of platelets. This can lead to an increased risk of bleeding.
Explanation for other choices:
B: Increased erythrocyte sedimentation rate (ESR) is not typically associated with ITP.
C: Decreased megakaryocytes may be seen in some cases of ITP but is not a consistent finding.
D: Increased WBC is not a characteristic finding in ITP.
Therefore, the most relevant finding in a client with ITP would be a decreased platelet count due to the underlying pathophysiology of the condition.
A nurse is caring for a client who is in labor and receiving oxytocin. Which of the following findings indicates that the nurse should increase the rate of infusion?
- A. Contractions every 5 min that last 30 seconds
- B. Montevideo units consistently 300 mm Hg
- C. Urine output of 20 mL/hr
- D. FHR pattern with absent variability
Correct Answer: A
Rationale: The correct answer is A because contractions every 5 minutes that last 30 seconds indicate increased frequency and duration, which may not be sufficient for effective labor progress. Increasing the rate of oxytocin can help strengthen contractions for more efficient labor. Choices B, C, and D do not indicate the need to increase the rate of infusion. Montevideo units measure the strength of contractions, urine output reflects renal perfusion, and absent variability in fetal heart rate suggests fetal distress, not the need for increased oxytocin.
A nurse is caring for a newborn who was transferred to the nursery 30 min after birth because of mild respiratory distress. Which of the following actions should the nurse take first?
- A. Confirm the newborn's Apgar score.
- B. Verify the newborn's identification.
- C. Administer vitamin K to the newborn.
- D. Determine obstetrical risk factors.
Correct Answer: B
Rationale: The correct answer is B: Verify the newborn's identification. This is the first action the nurse should take because ensuring proper identification is crucial for providing safe and effective care. By verifying the newborn's identification, the nurse can confirm they are caring for the right baby, preventing any potential errors in treatment or medication administration. This step is essential in maintaining patient safety and preventing harm.
Confirming the Apgar score (choice A) can be important but is not the first priority in this scenario. Administering vitamin K (choice C) is a routine procedure but can be done after verifying identification. Determining obstetrical risk factors (choice D) is important for overall assessment but is not the immediate priority.
A nurse is assessing a client who is at 30 weeks of gestation during a routine prenatal visit. Which of the following findings should the nurse report to the provider?
- A. Swelling of the face
- B. Varicose veins in the calves
- C. Nonpitting 1+ ankle edema
- D. Hyperpigmentation of the cheeks
Correct Answer: A
Rationale: The correct answer is A: Swelling of the face. This finding can indicate preeclampsia, a serious pregnancy complication characterized by high blood pressure and protein in the urine. Preeclampsia poses risks to both the mother and the baby, so prompt reporting to the provider is crucial for timely intervention. Varicose veins in the calves (B) are common in pregnancy due to increased pressure on the veins but do not require immediate provider notification. Nonpitting 1+ ankle edema (C) is a common finding in pregnancy and is not typically concerning unless it worsens significantly. Hyperpigmentation of the cheeks (D) is a common benign finding known as melasma and does not require immediate reporting unless accompanied by other concerning symptoms.