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A nurse is caring for a client who is in labor and notes that the umbilical cord is prolapsed. Which of the following actions should the nurse take?
- A. Evaluate uterine tone.
- B. Loosely wrap the cord with petroleum gauze.
- C. Apply fundal pressure.
- D. Place the client in Trendelenburg position
Correct Answer: D
Rationale: Placing the client in the Trendelenburg position helps reduce pressure on the prolapsed cord, preventing fetal distress. Other actions like applying fundal pressure or wrapping the cord are not appropriate.
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A nurse is reviewing the medical record of a client who had a vaginal delivery 3 hr ago. Which of the following findings place the client at risk for postpartum hemorrhage? (Select all that apply.)
- A. Labor induction with oxytocin
- B. Newborn weight 2.948 kg (6 lb 8 oz)
- C. Vacuum-assisted delivery
- D. History of uterine atony
- E. History of human papillomavirus
Correct Answer: A,C,D
Rationale: The correct answers are A, C, and D.
A: Labor induction with oxytocin can lead to uterine hyperstimulation, increasing the risk of postpartum hemorrhage.
C: Vacuum-assisted delivery can cause trauma to the birth canal, leading to increased bleeding.
D: History of uterine atony indicates a weak uterine muscle tone, which can result in excessive bleeding after delivery.
B: Newborn weight is not directly related to postpartum hemorrhage risk.
E: History of human papillomavirus does not increase the risk of postpartum hemorrhage.
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.
A nurse is teaching a client who is at 37 weeks of gestation and has a prescription for a nonstress test. Which of the following instructions should the nurse include?
- A. The test should take 10 to 15 minutes to complete.
- B. You will lie in a supine position throughout the test.
- C. You should not eat or drink for hours before the test.
- D. You should press the handheld button when you feel your baby move.
Correct Answer: D
Rationale: Pressing the handheld button when the client feels fetal movement helps to correlate fetal movements with changes in the fetal heart rate, which is the purpose of the nonstress test.
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 the correct choice because dairy products can worsen symptoms of hyperemesis gravidarum due to their high fat content, which can be difficult to digest. Eliminating dairy can help reduce nausea and vomiting.
Choice A is incorrect because focusing only on taste and not on balanced nutrition can worsen the condition. Choice B is incorrect as having a small snack before bed can actually help prevent nausea in the morning. Choice C is incorrect because hot tea may worsen nausea in some individuals.
Drag 1 condition and 1 client finding to fill in each blank in the following sentence. The client is at risk for developing -----------------due to-------------------
- A. Hypertension
- B. Vomiting
- C. Temperature
- D. Placenta abruption
- E. Spotaneous abortion
- F. Placenta previs
Correct Answer:
Rationale: