Nokea
A nurse monitors fetal well-being by means of an external monitor. At the peak of the contractions, the fetal heart rate has repeatedly dropped 30 beats/min below the baseline. Late decelerations are suspected and the nurse notifies the physician. Which is the rationale for this action?
- A. A nuchal cord (cord around the neck) is associated with variable decelerations, not late decelerations.
- B. Variable decelerations (not late decelerations) are associated with cord compression.
- C. Late decelerations are a result of hypoxia. They are not reflective of the strength of maternal contractions.
- D. Late decelerations are associated with uteroplacental insufficiency and are a sign of fetal hypoxia. Repeated late decelerations indicate fetal distress.
Correct Answer: D
Rationale: The correct answer is D because late decelerations are associated with uteroplacental insufficiency, resulting in fetal hypoxia. This is a sign of fetal distress, as indicated by the repeated drops in fetal heart rate during contractions. Late decelerations occur after the peak of the contraction, reflecting the delayed recovery of the fetal heart rate due to inadequate oxygen supply from the placenta. This prompts the nurse to notify the physician for further evaluation and intervention to address the underlying cause of fetal distress. Choices A, B, and C are incorrect because they do not accurately describe the characteristics and causes of late decelerations in fetal monitoring.
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A nurse is monitoring a child whose parents are suspected of child neglect. Which of the following is an expected finding of neglect?
- A. Lack of required immunizations
- B. Parental lack of education
- C. Lower socioeconomic group
- D. Faded clothing with large shoes
Correct Answer: A
Rationale: The correct answer is A: Lack of required immunizations. Neglect refers to the failure to provide for a child's basic needs, including healthcare. Lack of immunizations puts the child at risk for preventable diseases, indicating neglect. Parental lack of education (B) or being in a lower socioeconomic group (C) do not directly indicate neglect. Faded clothing with large shoes (D) may suggest financial difficulties but does not necessarily indicate neglect.
A nurse is discussing nutrition with an adolescent who is pregnant.
- A. "I told my daughter that any calories ingested are a source of energy and nutrition."'
- B. "I try to provide foods with an increased amount of calcium,protein and iron."'
- C. "I encourage between-meal snacks that are complex carbohydrates and fruits."'
- D. "I have planned meals and snacks for additional calories in the second and third trimester."'
Correct Answer: A
Rationale: Step 1: A is correct because it emphasizes the importance of calorie intake for energy and nutrition during pregnancy.
Step 2: Adolescents have higher calorie needs during pregnancy, making this advice crucial.
Step 3: B focuses on specific nutrients but doesn't address overall calorie intake.
Step 4: C mentions healthy snacks but doesn't emphasize the importance of calories.
Step 5: D mentions additional calories but lacks the focus on all calories being essential.
Step 6: A provides a comprehensive approach to nutrition during pregnancy, making it the correct choice.
In which position should the nurse place the laboring client in order to increase the intensity of the contractions and improve oxygenation to the fetus?
- A. Supine with legs elevated
- B. Squatting
- C. Left side-lying
- D. High Fowler's
Correct Answer: C
Rationale: The correct answer is C, left side-lying position. This position promotes optimal blood flow to the placenta, enhancing oxygenation to the fetus. It also helps prevent compression of the vena cava, ensuring adequate circulation to the mother. Supine position with legs elevated (A) can compress the vena cava, reducing blood flow to the fetus. Squatting (B) may not improve oxygenation to the fetus and can be tiring for the laboring client. High Fowler's position (D) can impede blood flow to the placenta due to compression of abdominal vessels.
During the first twelve hours following a normal vaginal delivery, the client voids 2,000 mL of urine. How should the nurse interpret this finding?
- A. Urinary tract infection
- B. High output renal failure
- C. Excessive use of IV fluids during delivery
- D. Normal diuresis after delivery
Correct Answer: D
Rationale: The correct interpretation is D: Normal diuresis after delivery. After childbirth, diuresis is common due to the body eliminating excess fluid retained during pregnancy. This process helps reduce swelling and aids in returning to pre-pregnancy state. Voiding 2,000 mL in the first twelve hours is within the expected range for postpartum diuresis. Choices A, B, and C are incorrect as they do not align with the typical physiologic response to childbirth. Urinary tract infection and high output renal failure would present with other symptoms, while excessive IV fluid use would not explain the timing or volume of urine output.
An hour after delivery, a 4000 gram infant exhibits pallor, jitteriness, a blood sugar level of 40 gm/dL, irritability and periodic apnea. Which maternal condition could be the cause of the newborn's symptoms?
- A. Drug addiction
- B. Pregnancy-induced hypertension
- C. TORCH infection
- D. Gestational diabetes
Correct Answer: D
Rationale: The correct answer is D: Gestational diabetes. Infants born to mothers with gestational diabetes are at risk for hypoglycemia due to excessive production of insulin in response to maternal hyperglycemia. This causes the infant's blood sugar level to drop, leading to symptoms such as pallor, jitteriness, irritability, and apnea. The maternal condition directly affects the newborn's blood sugar levels, explaining the infant's symptoms.
Choice A: Drug addiction does not directly cause hypoglycemia in the newborn.
Choice B: Pregnancy-induced hypertension would not typically result in hypoglycemia in the newborn.
Choice C: TORCH infections are unlikely to cause the specific symptoms described in the newborn.
In summary, only gestational diabetes directly affects the newborn's blood sugar levels, leading to the observed symptoms.