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A patient in labor is experiencing vaginal bleeding with no pain. What is the most likely cause?
- A. Placental abruption
- B. Placenta previa
- C. Uterine rupture
- D. Cervical laceration
Correct Answer: B
Rationale: The correct answer is B: Placenta previa. In placenta previa, the placenta partially or completely covers the cervix, leading to painless vaginal bleeding. Placental abruption (choice A) presents with painful bleeding. Uterine rupture (choice C) typically causes severe abdominal pain. Cervical laceration (choice D) usually occurs during delivery and is not typically associated with painless bleeding during labor. Placenta previa is the most likely cause in this scenario due to painless bleeding and the absence of contractions.
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A nurse is monitoring a laboring person who is receiving oxytocin for labor induction. What is the priority assessment during oxytocin infusion?
- A. monitor fetal heart rate
- B. assess maternal vital signs
- C. assess uterine tone
- D. monitor for signs of uterine hyperstimulation
Correct Answer: C
Rationale: The correct answer is C: assess uterine tone. This is the priority assessment during oxytocin infusion because oxytocin can cause uterine hyperstimulation, leading to fetal distress. By assessing uterine tone regularly, the nurse can detect any signs of hyperstimulation early and take appropriate action to prevent complications. Monitoring fetal heart rate (A) is important but assessing uterine tone takes precedence as it directly impacts fetal well-being. Maternal vital signs (B) are important but are not as directly related to the safety of the fetus during oxytocin infusion. Monitoring for signs of uterine hyperstimulation (D) is essential, but assessing uterine tone is the proactive approach to detect hyperstimulation before it escalates.
A laboring person on oxytocin for induction of labor should have continuous monitoring of the fetal heart rate. How often should the nurse assess the fetal heart rate?
- A. every 30 minutes
- B. every 15 minutes
- C. every 5 minutes
- D. every 1 hour
Correct Answer: B
Rationale: The correct answer is B: every 15 minutes. Continuous monitoring of the fetal heart rate is crucial during labor induction with oxytocin to promptly detect any signs of fetal distress. Assessing the fetal heart rate every 15 minutes allows for frequent monitoring to ensure the baby's well-being and timely intervention if needed. Assessing every 30 minutes (choice A) may not provide adequate monitoring frequency, every 5 minutes (choice C) is too frequent and may not be practical, and every 1 hour (choice D) is too long of an interval between assessments, potentially missing important changes in fetal status.
A biophysical profile is performed on a pregnant patient. The results show a nonreactive stress test (NST), three episodes of fetal breathing movements (FBMs), limited gross movements, opening and closing of the hand indicating the presence of fetal tone, and adequate amniotic fluid index (AFI). What is the correct interpretation of this test result?
- A. A score of 10 would indicate that the results are equivocal.
- B. A score of 8 would indicate normal results.
- C. A score of 6 would indicate that birth should be considered as a possible treatment option.
- D. A score of 9 would indicate reassurance.
Correct Answer: B
Rationale: A biophysical profile score of 8-10 is considered normal, indicating fetal well-being.
What is true about the morula stage of development?
- A. Fertilized egg has yet to implant
- B. Lung fields are completely formed
- C. Sex of fetus can be identified
- D. Eyelids begin to open and close
Correct Answer: A
Rationale: The morula stage occurs before implantation, representing an early phase of embryonic development.
A client is in the 10th week of her pregnancy. Which of the following symptoms would the nurse expect the client to exhibit? Select all that apply.
- A. Backache.
- B. Urinary frequency.
- C. Dyspnea on exertion.
- D. Fatigue.
Correct Answer: A
Rationale: Backache, urinary frequency, and fatigue are common symptoms during the first trimester. Dyspnea on exertion is more common later in pregnancy.