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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 in a woman’s health clinic is obtaining a health history from a client. Which of the following findings should the nurse identify as increasing the client’s risk for developing pelvic inflammatory disease (PID)?
- A. Recurrent Cystitis
- B. Frequent Alcohol Use
- C. Use of Oral Contraceptives
- D. Chlamydia Infection
Correct Answer: D
Rationale: The correct answer is D: Chlamydia Infection. Chlamydia is a common sexually transmitted infection that can lead to PID if left untreated. The bacteria can ascend from the cervix to the upper genital tract, causing inflammation and scarring. This increases the risk of PID. Recurrent Cystitis (A) is a urinary tract infection and not directly related to PID. Frequent Alcohol Use (B) does not directly increase the risk of developing PID. Use of Oral Contraceptives (C) actually decreases the risk of PID by reducing the chances of getting sexually transmitted infections.
A nurse is caring for a newborn boy, 6 hours old, whose bedside glucose meter reading is 65 mg/dL. The newborn's mother has Type 2 diabetes mellitus.
- A. Administer 50 mL of dextrose solution IV
- B. Obtain a blood sample of serum glucose level
- C. Reassess the blood glucose level prior to the next feeding
- D. Feed the newborn immediately
Correct Answer: D
Rationale: The correct answer is D: Feed the newborn immediately. By feeding the newborn, the nurse can stimulate the release of insulin, which will help regulate the baby's blood sugar levels. This is important especially in the case of a newborn born to a mother with Type 2 diabetes mellitus, as the baby may be at risk for hypoglycemia. Administering IV dextrose solution (choice A) is not necessary at this point as feeding is the initial intervention. Obtaining a blood sample for serum glucose level (choice B) can be done later but immediate feeding takes precedence. Reassessing blood glucose prior to the next feeding (choice C) may delay necessary intervention.
A nurse is caring for a client who is receiving oxytocin to induce labor. The nurse should discontinue the oxytocin if which of the following occurs?
- A. Contractions last 60 seconds
- B. Non-repetitive early decelerations
- C. 6 contractions in 10 minutes
- D. Moderate variability of the fetal heart rate
Correct Answer: A
Rationale: The correct answer is A: Contractions last 60 seconds. Prolonged contractions can lead to uterine hyperstimulation, which can decrease oxygen supply to the fetus, posing a risk of fetal distress. Discontinuing oxytocin in this situation is crucial to prevent further complications.
B: Non-repetitive early decelerations are not directly related to oxytocin administration and do not warrant discontinuation of the medication.
C: 6 contractions in 10 minutes is a sign of uterine hyperstimulation but alone may not be enough to discontinue oxytocin.
D: Moderate variability of the fetal heart rate is a reassuring sign of fetal well-being, not an indication to discontinue oxytocin.
A nurse is providing discharge teaching to a postpartum client about caring for her five-day-old male newborn at home.
- A. Retract the foreskin to clean your baby's penis during each bath
- B. Use triple antibiotic ointment on your baby's umbilical cord twice per day
- C. Swaddle your baby tightly with legs extended before laying him down to sleep
- D. Notify your baby's pediatrician if he urinates less than 6 times per day
Correct Answer: D
Rationale: The correct answer is D: Notify your baby's pediatrician if he urinates less than 6 times per day. This is important because adequate urine output is a sign of good hydration and kidney function in newborns. Notifying the pediatrician if the baby urinates less than 6 times a day can help identify any potential issues early on.
Choice A is incorrect because retracting the foreskin to clean the baby's penis is not recommended as it can lead to infections.
Choice B is incorrect because using triple antibiotic ointment on the umbilical cord is not necessary and can actually delay healing.
Choice C is incorrect because swaddling the baby tightly with legs extended can increase the risk of hip dysplasia.
Overall, it is important to focus on monitoring the baby's urine output and notifying the pediatrician if there are any concerns.
A nurse is teaching a client who is at 41 weeks of gestation about a non-stress test. Which of the following information should the nurse include in the teaching?
- A. This test will confirm fetal lung maturity
- B. This test will determine adequacy of placental perfusion
- C. This test will detect fetal infection
- D. This test will predict maternal readiness for labor
Correct Answer: B
Rationale: The correct answer is B: This test will determine the adequacy of placental perfusion. A non-stress test is used to assess fetal well-being by monitoring the fetal heart rate in response to fetal movement. The test helps determine if the placenta is providing enough oxygen to the fetus. Adequate placental perfusion is crucial for the well-being of the fetus. Option A is incorrect because a non-stress test does not confirm fetal lung maturity. Option C is incorrect because a non-stress test does not detect fetal infection. Option D is incorrect because a non-stress test does not predict maternal readiness for labor.