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 reviewing the laboratory results for a client who is at 29 weeks of gestation. Which of the following results should the nurse report to the provider?
- A. WBC count 11,000/mm³
- B. Hgb 11.2 g/dL
- C. Hct 34%
- D. Platelets 140,000/mm³
Correct Answer: D
Rationale: A platelet count of 140,000/mm³ is at the lower end of the normal range but can be concerning in pregnancy, especially if there are signs of thrombocytopenia or bleeding.
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.
A nurse is assessing a newborn who is 48 hr old and is experiencing opioid withdrawals. Which of the following findings should the nurse expect?
- A. Hypotonicity
- B. Moderate tremors of the extremities
- C. Axillary temperature 36.1° C (96.9° F)
- D. Excessive sleeping
Correct Answer: B
Rationale: Moderate tremors of the extremities are a common sign of opioid withdrawal in newborns. Other signs may include irritability, feeding difficulties, and gastrointestinal disturbances.
A nurse is assessing a newborn whose mother had gestational diabetes. Which of the following findings should the nurse identify as a manifestation of hypoglycemia?
- A. Hypertonia
- B. Jitteriness
- C. Acrocyanosis
- D. Generalized petechiae
Correct Answer: B
Rationale: Jitteriness is a common sign of hypoglycemia in newborns. Other signs may include irritability, poor feeding, and lethargy.
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.