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A nurse is caring for a laboring person who is experiencing fetal tachycardia. What is the priority intervention?
- A. administer oxygen
- B. monitor fetal heart rate
- C. increase fluid intake
- D. increase oxygen flow
Correct Answer: A
Rationale: The correct answer is A: administer oxygen. Fetal tachycardia indicates decreased oxygen supply to the fetus. Administering oxygen helps improve oxygenation to the fetus, addressing the root cause. Monitoring fetal heart rate (B) is important but not the priority over addressing the oxygen supply. Increasing fluid intake (C) does not directly address the fetal tachycardia. Increasing oxygen flow (D) is not necessary if the person is already receiving sufficient oxygen.
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A nurse is monitoring a laboring person who is receiving oxytocin for labor induction. What is the priority assessment during oxytocin infusion?
- A. monitor fetal heart rate
- B. assess maternal vital signs
- C. assess uterine tone
- D. monitor for signs of uterine hyperstimulation
Correct Answer: C
Rationale: The correct answer is C: assess uterine tone. This is the priority assessment during oxytocin infusion because oxytocin can cause uterine hyperstimulation, leading to fetal distress. By assessing uterine tone regularly, the nurse can detect any signs of hyperstimulation early and take appropriate action to prevent complications. Monitoring fetal heart rate (A) is important but assessing uterine tone takes precedence as it directly impacts fetal well-being. Maternal vital signs (B) are important but are not as directly related to the safety of the fetus during oxytocin infusion. Monitoring for signs of uterine hyperstimulation (D) is essential, but assessing uterine tone is the proactive approach to detect hyperstimulation before it escalates.
The nurse is educating a pregnant patient at 30 weeks gestation on the signs and symptoms of preterm labor. Which of the following should the nurse instruct the patient to report immediately?
- A. Mild cramping and back pain.
- B. Increased vaginal discharge.
- C. Regular contractions every 10 minutes or less.
- D. Feeling of pelvic pressure after physical activity.
Correct Answer: C
Rationale: The correct answer is C. Regular contractions every 10 minutes or less should be reported immediately as they could indicate preterm labor. The frequency and regularity of contractions are key indicators of labor starting. Other choices, A, B, and D, are common discomforts during pregnancy and not necessarily indicative of preterm labor. Mild cramping and back pain (A), increased vaginal discharge (B), and feeling of pelvic pressure after physical activity (D) are normal symptoms in pregnancy and not urgent signs of preterm labor.
A woman, 6 weeks pregnant, is having a vaginal examination. Which of the following would the practitioner expect to find?
- A. Thin cervical muscle.
- B. An enlarged ovary.
- C. Thick cervical mucus.
- D. Pale pink vaginal wall.
Correct Answer: B
Rationale: An enlarged ovary is a common finding in early pregnancy due to the corpus luteum. Thin cervical muscle, thick cervical mucus, and a pale pink vaginal wall are not typical findings at this stage.
What alternative could the nurse suggest to someone practicing pica?
- A. Replace laundry starch with salt
- B. Replace ice with frozen fruit juice
- C. Replace soap with cream cheese
- D. Replace soil with uncooked pie crust
Correct Answer: B
Rationale: Replacing ice with frozen fruit juice provides a safer alternative while satisfying the craving for cold substances.
When is the earliest interval that chorionic villus sampling (CVS) can be performed during pregnancy?
- A. 4 weeks
- B. 8 weeks
- C. 10 weeks
- D. 14 weeks
Correct Answer: C
Rationale: CVS is typically performed between 10 and 13 weeks of gestation to analyze fetal tissue for chromosomal, metabolic, or DNA abnormalities.