A nurse is monitoring a laboring person for signs of fetal distress. Which finding is most indicative of fetal distress?
- A. bradycardia
- B. tachycardia
- C. late decelerations
- D. variable decelerations
Correct Answer: A
Rationale: The correct answer is A: bradycardia. Fetal distress is often indicated by a decreased fetal heart rate (bradycardia), which can be a sign of inadequate oxygenation. Bradycardia is a serious concern in labor and requires immediate intervention. Tachycardia (B) is an increased heart rate, which can indicate fetal distress but is not as specific as bradycardia. Late decelerations (C) are associated with uteroplacental insufficiency, not necessarily fetal distress. Variable decelerations (D) are often related to cord compression and can be a sign of fetal distress, but bradycardia is a more direct indicator.
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A 38-week gestation client, Bishop score 1, is advised by her nurse midwife to take evening primrose daily. The office nurse advises the client to report which of the following side effects that has been attributed to the oil?
- A. Diarrhea.
- B. Pedal edema.
- C. Blurred vision.
- D. Tinnitus.
Correct Answer: A
Rationale: Diarrhea is a known side effect of evening primrose oil. Pedal edema, blurred vision, and tinnitus are not typically associated with its use.
A woman in labor begins to experience a sudden increase in vaginal bleeding and the fetal heart rate decelerates. What is the likely cause of these symptoms?
- A. Placenta previa
- B. Placental abruption
- C. Uterine rupture
- D. Cervical laceration
Correct Answer: B
Rationale: The correct answer is B: Placental abruption. Placental abruption is the premature separation of the placenta from the uterine wall, leading to vaginal bleeding and fetal distress. The sudden increase in bleeding and fetal heart rate deceleration are hallmark signs of placental abruption. Placenta previa (choice A) involves bleeding without fetal distress. Uterine rupture (choice C) typically presents with severe abdominal pain and shock. Cervical laceration (choice D) would not cause fetal heart rate deceleration.
A pregnant patient is concerned about the use of caffeine during pregnancy. Which of the following statements by the nurse would be most appropriate?
- A. Caffeine is completely safe during pregnancy and has no impact on the baby.
- B. Moderate caffeine consumption is safe, but it is recommended to limit it to 200 mg per day.
- C. You should avoid caffeine completely to prevent any complications.
- D. Caffeine can cause premature labor, so it should be avoided entirely.
Correct Answer: B
Rationale: The correct answer is B. Moderate caffeine consumption is safe, but it is recommended to limit it to 200 mg per day during pregnancy. This answer is appropriate because it balances the potential risks of caffeine with the benefits of moderate consumption. Excessive caffeine intake has been associated with adverse pregnancy outcomes, so setting a limit is a prudent approach.
Explanation for Incorrect Choices:
A: This statement is incorrect as excessive caffeine intake during pregnancy can have negative effects on the baby.
C: Complete avoidance of caffeine is not necessary unless the individual has specific health concerns that warrant it.
D: While high levels of caffeine can be linked to complications, the statement that caffeine always causes premature labor is an oversimplification.
Which statement about fetal circulation is correct?
- A. The foramen ovale is between ventricles
- B. Umbilical vein contains oxygen-poor blood
- C. Right atrium contains mixed blood
- D. Ductus venosus lies between aorta and pulmonary artery
Correct Answer: C
Rationale: The right atrium contains both oxygen-rich and oxygen-poor blood due to the unique fetal circulatory system.
A nurse is caring for a laboring person who is receiving oxytocin for labor induction. What is the priority intervention when uterine hyperstimulation occurs?
- A. stop the oxytocin infusion
- B. increase the oxytocin infusion
- C. administer IV fluids
- D. administer an epidural
Correct Answer: D
Rationale: The correct answer is D: administer an epidural. Uterine hyperstimulation during labor can lead to fetal distress and complications. Administering an epidural can help manage pain and relax the uterus, reducing the risk of hyperstimulation. Stopping the oxytocin infusion (choice A) is also important, but managing the uterine contractions with an epidural takes priority. Increasing the oxytocin infusion (choice B) would exacerbate the hyperstimulation. Administering IV fluids (choice C) may be helpful, but it does not directly address the uterine hyperstimulation.