Nokea
A nurse is caring for a client who is receiving oxytocin to augment labor. The client has an intrauterine pressure catheter and an internal fetal scalp electrode for monitoring. Which of the following is an indication that the nurse should discontinue the infusion?
- A. Contraction frequency every 3 min
- B. Contraction duration of 100 seconds
- C. Fetal heart rate with moderate variability
- D. Fetal heart rate of 118/min
Correct Answer: B
Rationale: A contraction duration of 100 seconds indicates potential uterine hyperstimulation, which can lead to fetal distress and decreased uterine perfusion. The nurse should discontinue the oxytocin infusion immediately to ensure the safety of both mother and fetus.
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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 providing education to a client in the first trimester of pregnancy. What information should the nurse include regarding the cause of indigestion and heartburn?
- A. Estrogen causes increased appetite
- B. Progesterone causes relaxation of the cardiac sphincter allowing acid to reflux
- C. HCG hormone leads to increased gastric acidity
- D. The uterus compresses the stomach early in pregnancy
Correct Answer: B
Rationale: Progesterone causes relaxation of the smooth muscles in the body, including the cardiac sphincter. This allows stomach acid to reflux into the esophagus, causing heartburn, especially during pregnancy.
A nurse is reviewing a laboratory report for a client who is at 33 weeks of gestation and has preeclampsia. Which of the following laboratory results should the nurse report to the provider?
- A. BUN 35 mg/dL
- B. Hgb 15 mg/dL
- C. Bilirubin 0.6 mg/dL
- D. Hct 37%
Correct Answer: A
Rationale: A BUN of 35 mg/dL indicates potential kidney impairment, which is a concern in preeclampsia due to compromised renal function. This finding warrants further evaluation by the provider.
A nurse is assessing a pregnant client at 32 weeks gestation and notes that the client has gained 5 pounds in one week. Which of the following conditions should the nurse suspect?
- A. Preeclampsia
- B. Gestational diabetes
- C. Anemia
- D. Placenta previa
Correct Answer: A
Rationale: Rapid weight gain, especially in the third trimester, can be a sign of preeclampsia, a condition characterized by hypertension, edema, and proteinuria. This requires immediate medical attention.
A nurse is assessing a client who gave birth 1 week ago. The client states, "I don't know what's wrong. I love my baby, but I feel so let down and I seem to cry for no reason." The nurse should identify that the client is experiencing which of the following emotional responses to birth?
- A. Postpartum depression
- B. Taking-in phase
- C. Postpartum blues
- D. Taking-hold phase
Correct Answer: C
Rationale: The client is likely experiencing postpartum blues, which is common and characterized by mood swings, tearfulness, and emotional letdown shortly after delivery.