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 used to assess fetal well-being by monitoring the baby's heart rate and uterine contractions. Oligohydramnios, which is low amniotic fluid levels, can indicate fetal distress and compromise, necessitating closer monitoring. Hyperemesis gravidarum (B) is severe nausea and vomiting, not directly related to fetal monitoring. Leukorrhea (C) is normal vaginal discharge during pregnancy and not a reason for fetal monitoring. Periodic tingling of the fingers (D) is unrelated to fetal assessment.
You may also like to solve these questions
A nurse is calculating the estimated date of delivery for a client who reports that the first day of her last menstrual period was August 10. Using Nägele’s Rule, which of the following is the client’s estimated date of delivery?
- A. May 13
- B. May 17
- C. May 3
- D. May 20
Correct Answer: B
Rationale: The correct answer is B: May 17. Nägele's Rule involves adding 7 days to the first day of the last menstrual period, subtracting 3 months, and then adding 1 year. In this case, starting from August 10, add 7 days to get August 17. Next, subtract 3 months to get May 17, and finally add 1 year to get the estimated date of delivery as May 17. Choice A (May 13) is incorrect as it does not follow the correct calculation steps. Choice C (May 3) is incorrect as it miscalculates the months. Choice D (May 20) is incorrect as it does not consider the subtraction of 3 months.
A nurse is caring for a client who is to receive oxytocin to augment their labor. Which of the following findings contraindicates the initiation of the oxytocin infusion and should be reported to the provider?
- A. Late decelerations
- B. Moderate variability of the FHR
- C. Cessation of uterine dilation
- D. Prolonged active phase of labor
Correct Answer: A
Rationale: The correct answer is A: Late decelerations. Late decelerations indicate uteroplacental insufficiency, which can worsen with oxytocin administration due to increased uterine contractions. This can lead to fetal distress and hypoxia. Late decelerations are a sign to stop or decrease the oxytocin infusion and notify the provider. Moderate variability of the FHR (B) is a reassuring sign of fetal well-being. Cessation of uterine dilation (C) may indicate a stalled labor but is not a contraindication for initiating oxytocin. Prolonged active phase of labor (D) may warrant oxytocin augmentation but is not a contraindication.
The nurse is assessing the client 24 hr later. How should the nurse interpret the findings?
- A. Hematuria
- B. Proteinuria 2+
- C. Leukorrhea
- D. Positive clonus
- E. BUN 40 mg/dL
- F. Platelet count 110,000/mm3
Correct Answer:
Rationale: Correct Answer:
Rationale:
- Hematuria and Proteinuria 2+ are signs of potential worsening conditions that the nurse should interpret as concerning findings.
- Positive clonus is a sign of potential improvement, indicating a positive response to treatment.
- Leukorrhea is unrelated to the diagnosis and should not be a focus of interpretation after 24 hours.
- BUN 40 mg/dL and Platelet count 110,000/mm3 are not provided in the question and thus cannot be interpreted.
A nurse is assessing a newborn 12 hr after birth. Which of the following manifestations should the nurse report to the provider?
- A. Acrocyanosis
- B. Transient strabismus
- C. Jaundice
- D. Caput succedaneum
Correct Answer: C
Rationale: The correct answer is C: Jaundice. Jaundice in a newborn within the first 24 hours of life can be indicative of pathological conditions such as hemolytic disease or liver dysfunction. The nurse should report this to the provider promptly for further evaluation and management. Acrocyanosis (A) and caput succedaneum (D) are common and normal findings in newborns. Transient strabismus (B) is also common and typically resolves on its own. Make sure to assess for any other concerning symptoms and report them as well.
A nurse is teaching about clomiphene citrate to a client who is experiencing infertility. Which of the following adverse effects should the nurse include?
- A. Breast tenderness
- B. Tinnitus
- C. Urinary frequency
- D. Chills
Correct Answer: A
Rationale: The correct answer is A: Breast tenderness. Clomiphene citrate is known to cause breast tenderness as a common adverse effect due to its estrogen-like effects. This occurs because clomiphene citrate can increase estrogen levels in the body, leading to breast discomfort. Tinnitus (B), urinary frequency (C), and chills (D) are not typically associated with clomiphene citrate use. Tinnitus is more commonly linked to ototoxic medications, urinary frequency may occur with diuretics, and chills are often seen with infections or febrile illnesses. Therefore, the nurse should emphasize breast tenderness as a potential side effect of clomiphene citrate to the client.