Nokea
A nurse is planning care for a client who is in labor and is to have an amniotomy. Which of the following assessments should the nurse identify as the priority?
- A. O2 saturation.
- B. Temperature.
- C. Blood pressure.
- D. Urinary output.
Correct Answer: B
Rationale: The correct answer is B: Temperature. During an amniotomy, there is a risk of infection due to the introduction of bacteria into the amniotic sac. Monitoring the client's temperature is crucial as fever can indicate infection, which can be life-threatening for both the client and the fetus. It is essential to detect early signs of infection to initiate prompt treatment. Assessing O2 saturation, blood pressure, and urinary output are important but not the priority in this situation. O2 saturation may be monitored if there are concerns about fetal distress, blood pressure for signs of preeclampsia, and urinary output for kidney function, but these are not immediate concerns post-amniotomy.
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A nurse is preparing to perform Leopold maneuvers for a client. Identify the sequence the nurse should follow. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
- A. Identify the attitude of the head.
- B. Palpate the fundus to identify the fetal part.
- C. Determine the location of the fetal back.
- D. Palpate for the fetal part presenting at the inlet.
Correct Answer: B, C, D, A
Rationale: The correct order for performing Leopold maneuvers is B, C, D, A. Firstly, palpating the fundus (B) helps identify the fetal part. Next, determining the location of the fetal back (C) gives insight into the baby's position. Palpating for the fetal part at the inlet (D) helps determine the presenting part. Finally, identifying the attitude of the head (A) concludes the assessment. The other choices do not align with the sequential nature of Leopold maneuvers, making them incorrect.
A nurse is reviewing the medical record of a newly admitted client who is at 32 weeks of gestation. Which of the following conditions is an indication for fetal assessment using electronic fetal monitoring?
- A. Oligohydramnios.
- B. Hyperemesis gravidarum.
- C. Leukorrhea.
- D. Periodic tingling of the fingers.
Correct Answer: A
Rationale: The correct answer is A: Oligohydramnios. Electronic fetal monitoring is used to assess the well-being of the fetus during pregnancy, labor, and delivery. Oligohydramnios refers to a low level of amniotic fluid, which can indicate fetal distress or compromise. Monitoring the fetal heart rate patterns using electronic fetal monitoring in this case can help detect any abnormalities and guide appropriate interventions to optimize fetal outcomes.
Incorrect choices:
B: Hyperemesis gravidarum - This is severe nausea and vomiting in pregnancy, not a direct indication for fetal monitoring.
C: Leukorrhea - This is a common vaginal discharge in pregnancy, not a direct indication for fetal monitoring.
D: Periodic tingling of the fingers - This is not related to fetal assessment and is more likely a symptom of a different issue, such as nerve compression.
A nurse is caring for a newborn who was transferred to the nursery 30 min after birth because of mild respiratory distress. Which of the following actions should the nurse take first?
- A. Confirm the newborn's Apgar score.
- B. Verify the newborn's identification.
- C. Administer vitamin K to the newborn.
- D. Determine obstetrical risk factors.
Correct Answer: B
Rationale: The correct answer is B: Verify the newborn's identification. This is the first action the nurse should take because ensuring proper identification is crucial for providing safe and effective care. By verifying the newborn's identification, the nurse can confirm they are caring for the right baby, preventing any potential errors in treatment or medication administration. This step is essential in maintaining patient safety and preventing harm.
Confirming the Apgar score (choice A) can be important but is not the first priority in this scenario. Administering vitamin K (choice C) is a routine procedure but can be done after verifying identification. Determining obstetrical risk factors (choice D) is important for overall assessment but is not the immediate priority.
A nurse is caring for a client who is at 41 weeks of gestation and has a positive contraction stress test. For which of the following diagnostic tests should the nurse prepare the client?
- A. Percutaneous umbilical blood sampling.
- B. Amnioinfusion.
- C. Biophysical profile (BPP).
- D. Chorionic villus sampling (CVS).
Correct Answer: C
Rationale: The correct answer is C: Biophysical profile (BPP). At 41 weeks gestation with a positive contraction stress test, the client may be at risk for uteroplacental insufficiency. A BPP assesses fetal well-being by evaluating fetal movement, tone, breathing, amniotic fluid volume, and fetal heart rate reactivity. This test helps determine if the fetus is getting enough oxygen and nutrients. Preparing the client for a BPP is crucial in monitoring the fetal status and making decisions regarding further management.
Incorrect choices:
A: Percutaneous umbilical blood sampling is an invasive procedure used to evaluate fetal blood gases and acid-base status, typically performed when there are concerns about fetal well-being like severe growth restriction or Rh incompatibility.
B: Amnioinfusion is the infusion of fluid into the amniotic cavity and is used to correct oligohydramnios (low amniotic fluid volume).
D: Chorionic villus
A nurse is assessing a client who is in active labor. Which of the following findings should the nurse report to the provider?
- A. Contractions lasting 80 seconds.
- B. Early decelerations in the PHR.
- C. Temperature 37.4° C (99 3* F).
- D. PHR baseline 170/min.
Correct Answer: D
Rationale: The correct answer is D: PHR baseline 170/min. A baseline fetal heart rate of 170/min is considered tachycardia and may indicate fetal distress, requiring immediate attention. This finding can be indicative of fetal hypoxia or other complications. The nurse should report this to the provider promptly for further evaluation and intervention.
Contractions lasting 80 seconds (choice A) are within the normal range for active labor and do not necessarily require immediate reporting.
Early decelerations in the PHR (choice B) are benign and typically not a cause for concern unless they are persistent or associated with other abnormal findings.
A temperature of 37.4°C (99.3°F) (choice C) is within normal limits and does not require immediate reporting unless it continues to rise significantly.
In summary, the correct answer is D because a baseline fetal heart rate of 170/min is abnormal and potentially indicative of fetal distress, requiring immediate provider notification.