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A nurse is preparing to assess fetal heart tones for a client who is at 12 weeks of gestation. Which of the following actions should the nurse take?
- A. Place the client in a side-lying position prior to assessing the fetal heart rate
- B. Measure the fundal height to determine the placement of the ultrasound stethoscope.
- C. Position the ultrasound stethoscope above the symphysis pubis to assess the fetal heart rate.
- D. Perform Leopold maneuvers prior to auscultating the fetal heart rate.
Correct Answer: C
Rationale: At 12 weeks of gestation, the fetal heart rate is best assessed using an ultrasound stethoscope positioned above the symphysis pubis. Leopold maneuvers are not necessary at this early stage.
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Which of the following is a potential complication of meconium aspiration syndrome?
- A. Respiratory distress syndrome
- B. Hypoglycemia
- C. Jaundice
- D. All of the above
Correct Answer: A
Rationale: The correct answer is A: Respiratory distress syndrome. Meconium aspiration can lead to airway obstruction, inflammation, and surfactant dysfunction, resulting in respiratory distress syndrome. Hypoglycemia and jaundice are not directly associated with meconium aspiration syndrome. Therefore, choice A is the most appropriate complication.
A nurse is providing teaching to the parents of a newborn about the Plastibell circumcision technique. Which of the following information should the nurse include?
- A. The Plastibell will be removed 4 hours after the procedure.
- B. Make sure the newborn’s diaper is snug.
- C. Yellow exudate will form at the surgical site in 24 hours.
- D. Notify the provider if the end of your baby’s penis appears dark red.
Correct Answer: D
Rationale: Correct Answer: D: Notify the provider if the end of your baby’s penis appears dark red.
Rationale: Dark red color at the end of the baby's penis could indicate infection or poor circulation, which are concerning post-circumcision. Promptly notifying the provider can help prevent potential complications.
Summary of other choices:
A: The Plastibell is usually removed after a few days, not 4 hours.
B: Ensuring a snug diaper is not directly related to the Plastibell circumcision technique.
C: Yellow exudate at the surgical site is normal and expected, not a cause for concern.
E, F, G: Not provided in the question, so not applicable.
A nurse is caring for a client following an amniocentesis at 18 weeks of gestation. Which of the following findings should the nurse report to the provider as a potential complication?
- A. Increased fetal movement.
- B. Leakage of fluid from the vagina.
- C. Upper abdominal discomfort.
- D. Urinary frequency.
Correct Answer: B
Rationale: Leakage of fluid from the vagina after an amniocentesis may indicate rupture of the amniotic membranes, which is a potential complication that requires immediate medical attention.
A nurse is reviewing the prescriptions for a client who is pregnant and is taking digoxin. Which of the following actions should the nurse take to best evaluate the client’s medication adherence?
- A. Ask the client if they are taking the medication as prescribed.
- B. Assess the client’s kidney function.
- C. Determine the client’s apical pulse rate.
- D. Check the client’s serum medication level.
Correct Answer: D
Rationale: The correct answer is D: Check the client’s serum medication level. This is the best action to evaluate medication adherence for digoxin in a pregnant client. Serum medication levels provide an objective measure of how much of the drug is present in the body, indicating if the client is taking the medication as prescribed. Asking the client directly (choice A) may not always yield accurate information. Assessing kidney function (choice B) is important for monitoring potential side effects of digoxin but does not directly assess medication adherence. Determining the apical pulse rate (choice C) is important for monitoring digoxin therapy but does not evaluate medication adherence.
The nurse is assessing the client 30 min later. How should the nurse interpret the findings? For each finding, click to specify whether the finding is unrelated to the diagnosis, an indication of potential improvement, or an indication of potential worsening condition.
- A. Fundus at level of umbilicus
- B. Cloudy urine
- C. Blood pressure 80/50 mm Hg
- D. Moderate lochia rubra
- E. Thready pulse
- F. Fundus firm to palpation
Correct Answer:
Rationale: Findings indicating improvement: Fundus at umbilicus, Moderate lochia rubra, Fundus firm to palpation Findings indicating worsening: Blood pressure 80/50 mm Hg, Thready pulse Unrelated finding: Cloudy urine Clinical Implication: The nurse should urgently address the low blood pressure and thready pulse, as they indicate ongoing hemodynamic instability due to postpartum hemorrhage. Immediate interventions such as IV fluids, blood transfusion, and further uterotonic medications may be necessary.