Nokea
A nurse is caring for a client who is in active labor and notes the FHR baseline has been 100/min for the past 15 min. The nurse should identify which of the following conditions as a possible cause of fetal bradycardia?
- A. Maternal hypoglycemia
- B. Chorioamnionitis
- C. Fetal anemia
- D. Maternal fever
Correct Answer: C
Rationale: Fetal anemia can lead to bradycardia due to reduced oxygen delivery to the fetal heart.
You may also like to solve these questions
A nurse is providing dietary teaching to a client who has hyperemesis gravidarum. Which of the following statements by the client indicates an understanding of the teaching?
- A. "I will eat foods that taste good instead of balancing my meals."
- B. "I will avoid having a snack before I go to bed each night."
- C. "I will have a cup of hot tea with each meal."
- D. "I will eliminate products that contain dairy from my diet."
Correct Answer: D
Rationale: The correct answer is D: "I will eliminate products that contain dairy from my diet." This is because hyperemesis gravidarum is a condition characterized by severe nausea and vomiting during pregnancy. Dairy products can be harder to digest and may exacerbate nausea. By eliminating dairy, the client can reduce the likelihood of triggering nausea and vomiting.
A: "I will eat foods that taste good instead of balancing my meals." - This statement does not address the dietary changes needed for hyperemesis gravidarum.
B: "I will avoid having a snack before I go to bed each night." - While avoiding snacks before bedtime can be a good practice for some, it does not specifically address the dietary needs of hyperemesis gravidarum.
C: "I will have a cup of hot tea with each meal." - Hot tea may not necessarily help with managing hyperemesis gravidarum symptoms and does not address the need for dietary modifications.
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: Contractions every 5 minutes lasting 30 seconds are inadequate for labor progression, indicating the need to increase oxytocin infusion to strengthen contractions.
A nurse is obtaining a 2-hr postprandial blood glucose from a client. Which of the following actions should the nurse take?
- A. Puncture the finger while still damp with antiseptic solution.
- B. Smear the blood onto the reagent strip.
- C. Hold the finger above the heart prior to puncture.
- D. Select the lateral side of the finger for puncture.
Correct Answer: D
Rationale: The correct answer is D: Select the lateral side of the finger for puncture. This is important because the lateral side of the finger has fewer nerve endings, which can reduce pain for the client. Puncturing the finger while still damp with antiseptic solution (choice A) can dilute the blood sample and affect the accuracy of the test. Smearing the blood onto the reagent strip (choice B) can lead to incorrect results due to inadequate blood volume or improper application. Holding the finger above the heart prior to puncture (choice C) can increase blood flow and may result in a higher blood glucose reading. Therefore, selecting the lateral side of the finger for puncture is the most appropriate action to ensure accurate and less painful blood glucose monitoring.
What is the primary intervention for postpartum hemorrhage?
- A. Oxytocin infusion
- B. Methylergonovine injection
- C. Misoprostol administration
- D. Blood transfusion
Correct Answer: A
Rationale: The correct answer is A: Oxytocin infusion. Oxytocin is the first-line medication for postpartum hemorrhage as it helps to contract the uterus, reducing bleeding. It stimulates uterine contractions, which helps to control bleeding by compressing blood vessels. Methylergonovine (B) is contraindicated in hypertensive disorders, Misoprostol (C) is an alternative if oxytocin is not available, and Blood transfusion (D) is a supportive measure after the bleeding is controlled.
A nurse is assessing a newborn who was born at 26 weeks of gestation using the New Ballard Score. Which of the following findings should the nurse expect?
- A. Minimal arm recoil
- B. Popliteal angle of 90°
- C. Creases over the entire foot sole
- D. Raised areolas with 3 to 4 mm buds
Correct Answer: A
Rationale: The correct answer is A: Minimal arm recoil. In premature newborns, the lack of muscle tone results in minimal arm recoil, which is a characteristic finding in the New Ballard Score for assessing gestational age. This is due to the immaturity of the neuromuscular system in premature infants. Choice B, popliteal angle of 90°, is incorrect as flexion of the hips and knees is more common in preterm infants. Choice C, creases over the entire foot sole, is incorrect as full development of foot sole creases is seen in term infants. Choice D, raised areolas with 3 to 4 mm buds, is incorrect as these are signs of breast development and are not specific to gestational age assessment.