Nokea
A nurse is caring for a client who is in active labor. The nurse notes early decelerations in the FHR on the fetal monitor tracing. The nurse should identify that which of the following conditions causes early decelerations in the FHR?
- A. Fetal hypoxemia
- B. Cord compression
- C. Uteroplacental insufficiency
- D. Head compression
Correct Answer: D
Rationale: Early decelerations are typically caused by head compression during contractions, which is a normal response and often indicates that the fetus is descending into the birth canal.
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A nurse is caring for a client who is 28 weeks pregnant and has preeclampsia. Which of the following is the priority assessment?
- A. Level of consciousness
- B. Deep tendon reflexes
- C. Blood pressure
- D. Urinary output
Correct Answer: C
Rationale: Blood pressure is the priority assessment in clients with preeclampsia because hypertension is the primary symptom of the condition. Elevated blood pressure increases the risk of complications such as eclampsia and placental abruption.
A nurse is caring for a client who is in the transition phase of labor. Which of the following actions should the nurse take?
- A. Assist the client to void every 3 hr
- B. Monitor contractions every 30 min
- C. Place the client into a lithotomy position
- D. Encourage the client to use a pant-blow breathing pattern
Correct Answer: D
Rationale: Encouraging the client to use a pant-blow breathing pattern helps manage pain and anxiety during the transition phase, which is characterized by intense contractions and emotional responses.
A nurse is assessing a client who is 24 hours postpartum. Which of the following findings should the nurse report to the healthcare provider?
- A. Uterine fundus is firm and midline
- B. Client's perineal pad is saturated in 15 minutes
- C. Client reports breast tenderness when breastfeeding
- D. Client's temperature is 100.4°F
Correct Answer: B
Rationale: A perineal pad saturated in 15 minutes is a sign of excessive postpartum bleeding, which requires immediate medical attention to prevent postpartum hemorrhage. The other findings are normal postpartum occurrences.
A nurse providing dietary teaching for a client who is at 29 weeks of gestation and has phenylketonuria. Which of the following suggested foods should the nurse include in the teaching?
- A. A peanut butter sandwich on wheat bread
- B. A sliced apple and red grapes
- C. A chocolate chip cookie with a glass of skim milk
- D. A scrambled egg with cheddar cheese
Correct Answer: B
Rationale: Clients with phenylketonuria (PKU) must adhere to a strict low-phenylalanine diet to prevent neurological damage. A sliced apple and red grapes are low in phenylalanine, making them safe choices.
A postpartum complication a client is at risk for is deep-vein thrombosis. Which of the following is a factor strongly associated with this postpartum complication?
- A. Cesarean birth
- B. Vaginal birth
- C. Anemia
- D. Multiparity
Correct Answer: A
Rationale: Cesarean birth doubles the risk for deep-vein thrombosis (DVT) due to immobility and vascular changes associated with surgery. Other risk factors include smoking, obesity, and a history of thromboembolism.