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A nurse is caring for a client who is receiving oxytocin for labor induction. Which of the following findings requires immediate intervention?
- A. Contraction frequency of every 3 minutes
- B. Contraction duration of 80 seconds
- C. Late decelerations in the fetal heart rate
- D. Urine output of 50 mL/hr
Correct Answer: C
Rationale: Late decelerations in the fetal heart rate require immediate intervention as they can indicate fetal distress due to uteroplacental insufficiency. This finding suggests a compromised blood flow to the fetus, which can lead to serious complications if not addressed promptly. Contraction frequency and duration are important to monitor but do not necessitate immediate intervention unless they are causing fetal distress. Urine output of 50 mL/hr is within the normal range for a client in labor and does not require immediate intervention.
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A nurse is assessing a newborn who was delivered 6 hours ago. Which of the following findings should the nurse report to the provider?
- A. Respiratory rate of 70/min
- B. Vernix caseosa covering the skin
- C. Milia on the bridge of the nose
- D. Acrocyanosis of the extremities
Correct Answer: A
Rationale: A respiratory rate of 70/min in a newborn is above the expected range and may indicate respiratory distress, which should be reported to the provider. Choice B, vernix caseosa covering the skin, is a normal finding in newborns and does not require reporting. Choice C, milia on the bridge of the nose, is also a common finding in newborns and does not require immediate reporting. Choice D, acrocyanosis of the extremities, is a common finding within the first few hours of life in newborns and typically resolves on its own, so it does not need to be reported.
A nurse is caring for a newborn who is large for gestational age (LGA). Which of the following findings should the nurse expect?
- A. Hyperbilirubinemia
- B. Hypoglycemia
- C. Hypercalcemia
- D. Hypothermia
Correct Answer: B
Rationale: Newborns who are large for gestational age (LGA) are at risk for hypoglycemia due to increased insulin production. Hyperbilirubinemia (Choice A) is more commonly associated with ABO or Rh incompatibility. Hypercalcemia (Choice C) is not a common finding in LGA newborns. Hypothermia (Choice D) may occur in newborns who are small for gestational age (SGA) due to a lack of subcutaneous fat for insulation, but it is not typically associated with LGA newborns.
A nurse is assessing a client who is at 34 weeks of gestation and is receiving magnesium sulfate for severe preeclampsia. Which of the following findings should the nurse report to the provider?
- A. Respiratory rate of 10/min
- B. Urine output of 30 mL/hr
- C. Deep tendon reflexes 2+
- D. Client reports feeling warm
Correct Answer: A
Rationale: A respiratory rate of 10/min is significantly low and indicates potential magnesium toxicity, which can lead to respiratory depression. This finding should be reported to the provider immediately for further evaluation and management. Urine output of 30 mL/hr is within the expected range during magnesium sulfate therapy and does not require immediate reporting. Deep tendon reflexes 2+ are a normal finding and do not indicate any immediate concerns. The client reporting feeling warm is a common side effect of magnesium sulfate and does not require immediate reporting unless accompanied by other symptoms.
A client at 37 weeks of gestation is scheduled for a nonstress test. What information should the nurse include?
- A. You will be given oxytocin during the test.
- B. You will need to fast for 12 hours before the test.
- C. You will need to drink orange juice before the test.
- D. You will need to have a full bladder during the test.
Correct Answer: C
Rationale: The correct answer is C. Drinking orange juice before the nonstress test can increase fetal movement, which is essential for an accurate reading. Choice A is incorrect because oxytocin is not typically administered during a nonstress test. Choice B is incorrect as fasting is not required before this test. Choice D is incorrect as a full bladder is not necessary for a nonstress test.
A client in the first trimester of pregnancy who is experiencing nausea is receiving teaching from a nurse. Which of the following instructions should the nurse include in the teaching?
- A. Drink water with meals
- B. Consume small, frequent meals
- C. Eat high-fat foods
- D. Lie down after eating
Correct Answer: B
Rationale: The correct instruction for a client in the first trimester of pregnancy experiencing nausea is to consume small, frequent meals. This helps alleviate nausea by preventing an empty stomach and maintaining stable blood sugar levels. Drinking water with meals can sometimes exacerbate nausea, especially in the case of morning sickness. Eating high-fat foods can be heavy on the stomach and worsen nausea. Lying down after eating can lead to reflux and is not recommended, especially for pregnant individuals experiencing nausea.