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A nurse is reviewing a laboratory report for a client who is at 33 weeks of gestation and has preeclampsia. Which of the following laboratory results should the nurse report to the provider?
- A. BUN 35 mg/dL
- B. Hgb 15 mg/dL
- C. Bilirubin 0.6 mg/dL
- D. Hct 37%
Correct Answer: A
Rationale: A BUN of 35 mg/dL indicates potential kidney impairment, which is a concern in preeclampsia due to compromised renal function. This finding warrants further evaluation by the provider.
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A nurse is teaching the parent of a newborn about car seat safety. Which of the following statements should the nurse make?
- A. You should keep the car seat rear-facing until your baby is at least 2 years old.
- B. Position the retainer clip over the upper part of your baby's abdomen.
- C. You should place your baby in the car seat at a 90-degree angle.
- D. Place the shoulder harness straps in the slots an inch above your baby's shoulders.
Correct Answer: A
Rationale: The car seat should remain rear-facing until at least 2 years old to ensure maximum safety in the event of a collision. This position helps protect the infant's head, neck, and spine.
A pregnant client's last menstrual period was May 4th, 2013. What is this client's estimated delivery date using Naegele's Rule?
- A. January 15, 2014
- B. February 11, 2014
- C. March 3, 2014
- D. December 25, 2013
Correct Answer: B
Rationale: Naegele's rule is a standard way of calculating an estimated delivery date (EDD). It involves subtracting three months from the first day of the last menstrual period (LMP), adding seven days, and then adding one year. In this case, subtracting three months from May 4th, 2013, gives February 4th. Adding seven days results in a due date of February 11th, 2014.
A nurse is conducting an infertility assessment for a newly admitted client. Which of the following factors should the nurse identify as affecting the client's fertility?
- A. Premature ovarian failure
- B. Renal calculi
- C. Dysmenorrhea
- D. Recurrent urinary tract infection
Correct Answer: A
Rationale: Premature ovarian failure affects fertility by leading to reduced or absent ovarian function, resulting in decreased estrogen production and irregular menstrual cycles.
A nurse is caring for a laboring client and notes that the fetal heart rate begins to decelerate after the contraction has started. The lowest point of deceleration occurs after the peak of the contraction. What is the priority nursing action?
- A. Administer oxygen
- B. Change the client's position
- C. Increase IV fluids
- D. Call the healthcare provider
Correct Answer: B
Rationale: Late decelerations are caused by uteroplacental insufficiency, indicating that the fetus is not receiving adequate oxygen during contractions. This is an emergency that requires prompt intervention. Changing the client's position helps to improve placental blood flow, which can reduce the stress on the fetus. If the decelerations continue, further interventions, including oxygen administration and notifying the provider, may be necessary.
A nurse is caring for a client in active labor who is receiving oxytocin. The nurse notes that the client is experiencing contractions every 1 minute lasting 90 seconds. Which of the following actions should the nurse take?
- A. Stop the oxytocin infusion
- B. Administer oxygen
- C. Increase the IV fluid rate
- D. Prepare for delivery
Correct Answer: A
Rationale: Contractions that are too frequent or prolonged can lead to uterine hyperstimulation, which can compromise fetal oxygenation. The nurse should stop the oxytocin infusion to reduce contraction frequency and intensity.