Nokea
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 indicated for assessing fetal well-being in pregnancies with conditions that may compromise fetal oxygenation, such as oligohydramnios. Oligohydramnios is a condition where there is an insufficient amount of amniotic fluid around the fetus, which can lead to fetal distress. Electronic fetal monitoring helps track the fetal heart rate and uterine contractions to detect signs of distress. Hyperemesis gravidarum (B), leukorrhea (C), and periodic tingling of the fingers (D) are not indications for fetal monitoring as they do not directly impact fetal well-being.
You may also like to solve these questions
A nurse is admitting a client to the labor and delivery unit when the client states, 'My water just broke.' Which of the following interventions is the nurse's priority?
- A. Perform Nitrazine testing.
- B. Assess the fluid.
- C. Check cervical dilation.
- D. Begin FHR monitoring.
Correct Answer: D
Rationale: The correct answer is D: Begin FHR monitoring. This is the priority intervention because it assesses the well-being of the fetus immediately after the client's water breaking. Monitoring the fetal heart rate can provide crucial information on the baby's status and help identify any signs of distress. Performing Nitrazine testing (A) or checking cervical dilation (C) can be done after ensuring fetal well-being. Assessing the fluid (B) can confirm if the amniotic sac has indeed ruptured but does not provide immediate information on fetal status.
A school nurse is providing teaching to an adolescent about levonorgestrel contraception. Which of the following information should the nurse include in the teaching?
- A. You should take the medication within 72 hours following unprotected sexual intercourse.
- B. You should avoid taking this medication if you are on an oral contraceptive.
- C. If you don't start your period within 5 days of taking this medication, you will need a pregnancy test.
- D. One dose of this medication will prevent you from becoming pregnant for 14 days after taking it.
Correct Answer: A
Rationale: The correct answer is A: You should take the medication within 72 hours following unprotected sexual intercourse. Levonorgestrel is most effective when taken within 72 hours after unprotected sex to prevent pregnancy. This timing is crucial for its efficacy.
Choice B is incorrect because levonorgestrel can be used in combination with oral contraceptives if needed. Choice C is incorrect as the absence of a period does not always indicate pregnancy, and a pregnancy test may not be necessary. Choice D is incorrect because levonorgestrel is effective for a shorter duration, not 14 days.
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: The correct answer is B: Leakage of fluid from the vagina. This finding could indicate an amniotic fluid leak, which is a potential complication following an amniocentesis. Amniotic fluid leakage can lead to infection and preterm labor. Increased fetal movement (choice A) is a normal sign of fetal well-being. Upper abdominal discomfort (choice C) and urinary frequency (choice D) are common after an amniocentesis and are not typically concerning unless severe or persistent.
A nurse is assessing a newborn who is 16 hr old. Which of the following findings should the nurse report to the provider?
- A. Substernal retractions.
- B. Acrocyanosis.
- C. Overlapping suture lines.
- D. Head circumference 33 cm (13 in).
Correct Answer: A
Rationale: The correct answer is A: Substernal retractions. Substernal retractions indicate respiratory distress in a newborn, which can be a serious issue requiring immediate medical attention. Acrocyanosis (choice B) is a common finding in newborns and is not concerning. Overlapping suture lines (choice C) can be normal in newborns and typically resolve on their own. A head circumference of 33 cm (13 in) (choice D) is within the normal range for a newborn.
A nurse is assessing a newborn who was born at 26 weeks of gestation using the New Ballard Score. Which of the following findings should the nurse expect?
- A. Minimal arm recoil.
- B. Popliteal angle of 90°.
- C. Creases over the entire foot sole.
- D. Raised areolas with 3 to 4 mm buds.
Correct Answer: A
Rationale: The correct answer is A: Minimal arm recoil. In preterm infants, particularly those born at 26 weeks of gestation, minimal arm recoil is expected due to underdeveloped muscle tone. This is a characteristic finding in the New Ballard Score assessment for preterm newborns. Option B, popliteal angle of 90°, is incorrect as preterm infants typically have a popliteal angle greater than 90°. Option C, creases over the entire foot sole, is also incorrect as preterm infants usually have a smooth foot sole without creases. Option D, raised areolas with 3 to 4 mm buds, is not relevant to the assessment of gestational age in preterm newborns.