Nokea
A nurse is performing an initial assessment of a multigravida patient who is 10 weeks gestation. Which assessment finding would necessitate further testing?
- A. Rubella titer ratio of 1:10
- B. Blood type A+
- C. White blood cell count of 5,000
- D. Previous history of gestational diabetes
Correct Answer: A
Rationale: Chadwick’s sign, which is the bluish coloration of the cervix, is an early positive sign of pregnancy. It indicates increased blood flow and is often noted during a pelvic examination.
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What is a common reason for cesarean birth?
- A. cephalic presentation
- B. laboring person’s BMI of 23
- C. labor dystocia
- D. lack of adequate pain control
Correct Answer: C
Rationale: Labor dystocia, or failure to progress, is a common reason for a cesarean birth.
The nurse recognizes that fetal scalp stimulation may be prescribed to evaluate the response of the fetus to tactile stimulation. Which conditions contraindicate the use of fetal scalp stimulation? (Select all that apply.)
- A. Post-term fetus
- B. Maternal fever
- C. Placenta previa
- D. Induction of labor
Correct Answer: A
Rationale: A. Post-term fetus: Fetal scalp stimulation can be contraindicated in post-term fetuses due to the potential risks associated with uterine hyperstimulation and decreased fetal reserve in these pregnancies.
What is the most likely cause for this fetal heart rate pattern?
- A. Administration of an epidural for pain relief during labor
- B. Cord compression
- C. Breech position of fetus
- D. Administration of meperidine (Demerol) for pain relief during labor
Correct Answer: B
Rationale: The fetal heart rate pattern described in the question, which likely includes decelerations, is indicative of cord compression. Cord compression occurs when there is pressure on the umbilical cord, leading to temporary reduction or blockage of blood flow and oxygen supply to the fetus. This can result in variable decelerations in the fetal heart rate pattern. Common scenarios that can cause cord compression include changes in fetal position, cord prolapse, or excessive uterine contractions. It is important to promptly address cord compression to prevent fetal distress and potential complications during labor and delivery. The other options listed may also influence fetal heart rate, but in this scenario, cord compression is the most likely cause based on the described heart rate pattern.
The nurse is caring for a postpartum person after a hemorrhage. How does the nurse monitor for decreased perfusion?
- A. Monitor lochia.
- B. Measure blood loss.
- C. Check temperature.
- D. Monitor 24-hour urine output.
Correct Answer: B
Rationale: After postpartum hemorrhage, monitoring the 24-hour urine output can help assess for signs of decreased perfusion.
When a Category II pattern of the fetal heart rate is noted and the patient is lying on her left side, which nursing action is indicated?
- A. Lower the head of the be
- B. Place a wedge under the left hip.
- C. Change her position to the right side
- D. Place the mother in Trendelenburg position
Correct Answer: C
Rationale: When a Category II pattern of fetal heart rate is noted, placing a wedge under the left hip of the pregnant patient is indicated. This position helps to improve blood flow to the placenta and can sometimes help to improve the fetal heart rate pattern. Placing the patient in a left lateral tilt can also be effective in improving circulation and oxygenation to the fetus. It is important to act promptly in response to abnormal fetal heart rate patterns to optimize the well-being of the baby. Lowering the head of the bed, changing the position to the right side, or placing the mother in Trendelenburg position are not appropriate actions in this situation.