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Client in labor, external fetal monitor, late decelerations
A nurse is caring for a client who is in labor and has an external fetal monitor. The nurse observes late decelerations on the monitor strip and interprets them as indicating which of the following?
- A. Uteroplacental insufficiency.
- B. Umbilical cord compression.
- C. Maternal bradycardia.
- D. Fetal head compression.
Correct Answer: A
Rationale: Late decelerations indicate uteroplacental insufficiency, where reduced placental blood flow during contractions causes fetal hypoxia.
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Early postpartum woman
Which maternal event is abnormal in the early postpartum period?
- A. Lochial color changes from rubra to alba.
- B. Extreme hunger and thirst.
- C. Diuresis and diaphoresis.
- D. Flatulence and constipation.
Correct Answer: B
Rationale: Extreme hunger and thirst may indicate abnormal blood sugar levels or metabolic issues, requiring further evaluation, unlike the other normal postpartum events.
Vacuum extraction birth
While assisting with a vacuum extraction birth, what should the nurse immediately report to the physician?
- A. Maternal pulse rate of 100 bpm.
- B. Maternal blood pressure of 120/70 mm Hg.
- C. Decrease in intensity of uterine contractions.
- D. Persistent fetal bradycardia below 100 bpm.
Correct Answer: D
Rationale: Persistent fetal bradycardia below 100 bpm indicates potential fetal distress, requiring immediate reporting to ensure fetal safety.
Newborn, 2 days old, lost 6 ounces since birth
A mother is upset because her newborn has lost 6 ounces since birth 2 days ago. The nurse informs the mother that it is normal for a newborn to lose which percentage of their birth weight within the first week of life?
- A. 10% to 15% of their birth weight.
- B. 20% of their birth weight.
- C. 15% to 18% of their birth weight.
- D. 5% to 10% of their birth weight.
Correct Answer: D
Rationale: 5% to 10% of their birth weight is correct because this range is within the normal limits for a newborn weight loss. Newborns lose some weight due to insufficient caloric intake, fluid loss, and metabolic adjustments in the first week after birth.
Woman received epidural or intrathecal opioids
The main nursing observations of the woman who receives epidural or intrathecal opioids are for all except
- A. delayed respiratory depression.
- B. inability to move lower extremities.
- C. pruritus.
- D. nausea and vomiting.
Correct Answer: A
Rationale: Delayed respiratory depression is not a primary concern with epidural or intrathecal opioids, which have limited systemic effects compared to systemic opioids.
Newborn reflex observation
Which newborn reflex elicits the following reaction: Head turns to one side - the way the head is facing, the arm/leg is stretched out while the other is bent?
- A. Tonic neck reflex.
- B. Moro reflex.
- C. Startled reflex.
- D. Babinski reflex.
Correct Answer: A
Rationale: The tonic neck reflex, also called the fencing posture, occurs when a baby's head is turned to one side, causing the arm and leg on that side to stretch out and the opposite side to bend, matching the described reaction.