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A nurse is caring for four clients. For which of the following clients should the nurse auscultate the fetal heart rate during the prenatal visit?
- A. A client who has an ultrasound that confirms a molar pregnancy
- B. A client who has a crown-rump length of 7 weeks gestation
- C. A client who has a positive urine pregnancy test 1 week after missed menses
- D. A client who has felt quickening for the first time
Correct Answer: D
Rationale: The correct answer is D. The nurse should auscultate the fetal heart rate for a client who has felt quickening for the first time during the prenatal visit. Quickening is the first fetal movements felt by the mother, typically occurring around 18-20 weeks gestation. Auscultating the fetal heart rate confirms the presence of fetal life and ensures the fetus is developing appropriately. This step is crucial in assessing fetal well-being and monitoring for any potential complications.
Choice A: A client with a molar pregnancy does not have a viable fetus; auscultating the fetal heart rate is not necessary.
Choice B: A client with a crown-rump length of 7 weeks gestation may be too early for fetal heart rate detection using auscultation.
Choice C: A positive urine pregnancy test alone does not indicate fetal viability; auscultation is needed to assess the fetus.
In summary, choice D is correct as it aligns with the timing of fetal movement and the need to assess
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A nurse is caring for a client who is in the second stage of labor. Which of the following manifestations should the nurse expect?
- A. The client expels the placenta
- B. The client experiences gradual dilation of the cervix
- C. The client begins have regular contractions.
- D. The client delivers the newborn
Correct Answer: D
Rationale: The correct answer is D. In the second stage of labor, the client delivers the newborn. This stage begins with full dilation of the cervix and ends with the birth of the baby. The expulsion of the placenta (Choice A) occurs in the third stage of labor. Gradual dilation of the cervix (Choice B) is characteristic of the first stage of labor. Regular contractions (Choice C) may occur throughout labor but are not specific to the second stage. So, the correct answer is D because it aligns with the chronological progression of labor stages.
A nurse on a labor and delivery unit is receiving infection control standards with a newly licensed nurse. The nurse should instruct the newly licensed nurse to don gloves for which of the following procedures?
- A. Assisting a mother with breastfeeding
- B. Performing a newborn’s initial bath
- C. Administering the measles, mumps, rubella vaccine
- D. Performing umbilical cord care
Correct Answer: D
Rationale: The correct answer is D: Performing umbilical cord care. Gloves should be worn when performing this procedure to prevent potential infection transmission. The umbilical cord stump is a point of entry for pathogens, making it important to maintain strict infection control. Assisting a mother with breastfeeding (A) does not require gloves unless there are open wounds or sores on the mother's breast. Performing a newborn’s initial bath (B) does not necessitate gloves unless there are specific concerns like skin conditions. Administering the measles, mumps, rubella vaccine (C) typically requires clean, not sterile, technique. In summary, wearing gloves during umbilical cord care is essential to prevent infection transmission, making it the correct choice in this scenario.
A nurse is assessing a newborn who was born Post term. Which of the following findings should the nurse expect?
- A. Nails extending over tips of fingers
- B. Large deposits of subcutaneous fat
- C. Pale, translucent skin
- D. Thin covering of fine hair on shoulders and back
Correct Answer: A
Rationale: The correct answer is A - Nails extending over tips of fingers. Post-term newborns may have longer nails due to prolonged exposure in utero. This is because the baby had more time for nail growth compared to a term baby. Nails extending over the tips of the fingers is a common finding in post-term newborns. The other choices are incorrect because large deposits of subcutaneous fat (B) are more common in term or postmature infants, pale, translucent skin (C) is more characteristic of preterm infants, and a thin covering of fine hair on shoulders and back (D) is typical of lanugo, which is usually shed before birth or shortly after for post-term infants.
A nurse is assessing a client who is 27 weeks of gestation and has pre-eclampsia. Which of the following findings should the nurse report to the provider?
- A. Hemoglobin 14.8 g/dL
- B. Platelet count 60,000/mm³
- C. Creatinine 0.8 mg/dL
- D. Urine protein concentration 200 mg/24hr
Correct Answer: B
Rationale: The correct answer is B: Platelet count 60,000/mm³. In pre-eclampsia, there is a risk of developing HELLP syndrome, which includes hemolysis, elevated liver enzymes, and low platelet count. A platelet count of 60,000/mm³ indicates thrombocytopenia, a serious complication that can lead to bleeding and should be reported to the provider urgently. Choices A, C, and D are within normal limits for a pregnant client and are not indicative of an immediate concern in pre-eclampsia.
A nurse is planning care for a client who is scheduled for a cesarian birth. Which of the following interventions should the nurse include in the plan of care?
- A. Instruct the client not to eat after midnight the night before
- B. Perform a surgical time out
- C. Shave the client’s abdomen at the preoperative visit
- D. Secure the clients hair to their scalp with metal hair pins
Correct Answer: B
Rationale: The correct answer is B: Perform a surgical time out. This step is crucial before any surgical procedure, including a cesarean birth, to ensure patient safety. During the time out, the surgical team verifies the patient's identity, correct procedure, correct site, and other essential details to prevent errors. In contrast, choice A is outdated practice as current guidelines allow clear fluids up to a few hours before surgery. Choice C is unnecessary and can increase the risk of infection. Choice D is incorrect as metal hairpins are not recommended due to the risk of injury and interference with surgical equipment.