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A patient vaginally delivered an infant at 4750 g moderate shoulder dystocia occurred during the birth. During the initial assessment of the infant the nurse should look for
- A. Erb's palsy
- B. Bell palsy
- C. Bradycardia
- D. Petechiae
Correct Answer: C
Rationale: The correct answer is C: Bradycardia. During shoulder dystocia, the infant may experience umbilical cord compression leading to decreased oxygen supply and potential bradycardia. Bradycardia is a critical sign that requires immediate attention. Erb's palsy (A) is a brachial plexus injury due to shoulder dystocia, not an immediate concern. Bell palsy (B) is a facial nerve paralysis unrelated to birth trauma. Petechiae (D) are small red or purple spots that may indicate bleeding disorders but are not specific to shoulder dystocia.
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The nurse is performing a nonstress test. What result indicates a reactive test?
- A. No fetal movements noted.
- B. Two accelerations in 20 minutes.
- C. Baseline fetal heart rate of 170 beats/minute.
- D. Variable decelerations.
Correct Answer: B
Rationale: The correct answer is B because two accelerations in 20 minutes are indicative of a reactive nonstress test. This pattern suggests that the fetal heart rate is reacting appropriately to fetal movement, indicating good oxygenation and neurologic integrity. Choice A is incorrect as fetal movements are essential for the test. Choice C is incorrect as a baseline heart rate of 170 bpm is considered high. Choice D is incorrect as variable decelerations are concerning for fetal distress.
The nurse is monitoring a client with hypertonic uterine contractions. What is the priority nursing action?
- A. Administer pain relief as prescribed.
- B. Prepare for an amniotomy.
- C. Encourage ambulation.
- D. Increase oxytocin infusion.
Correct Answer: A
Rationale: The correct answer is A: Administer pain relief as prescribed. The priority is to address the client's discomfort and pain caused by hypertonic uterine contractions. Pain management is crucial to ensure the client's comfort and well-being. Administering pain relief can help prevent complications such as increased stress on the mother and fetus.
Choice B: Prepare for an amniotomy is incorrect because it involves artificial rupturing of the amniotic sac, which is not indicated for hypertonic contractions.
Choice C: Encourage ambulation is incorrect because it may exacerbate the pain and discomfort experienced by the client with hypertonic uterine contractions.
Choice D: Increase oxytocin infusion is incorrect because it can further intensify the uterine contractions and worsen the client's pain.
The nurse is teaching the postpartum client about newborn transitional stool. Which should the nurse include in the teaching session? SATA
- A. They have greenish brown color
- B. They are looser consistency
- C. They are seedy with sweet sour smell
- D. They have tar like consistency
Correct Answer: A
Rationale: The correct answer is A because transitional stools in newborns typically have a greenish-brown color due to the presence of meconium and the changing composition of the stool as the baby starts digesting breastmilk or formula.
Rationale:
1. A: Greenish-brown color is characteristic of transitional stools as meconium is being passed out.
Incorrect answers:
2. B: Transitional stools are not necessarily looser in consistency.
3. C: Transitional stools are not typically described as seedy with a sweet-sour smell.
4. D: Tar-like consistency is more indicative of meconium, not transitional stools.
A nurse in a prenatal clinic is teaching a client who has a new prescription for dinoprostone gel. Which of the following statements should the nurse include in the teaching?
- A. "This medication promotes softening of the cervix."
- B. "This medication is used to treat preeclampsia."
- C. "It causes relaxation of the uterine muscles."
- D. "It is used to treat genital herpes simplex virus."
Correct Answer: A
Rationale: The correct answer is A: "This medication promotes softening of the cervix." Dinoprostone gel is a prostaglandin used to ripen the cervix in preparation for labor induction. This explanation is crucial for the client to understand the purpose of the medication. Option B is incorrect because dinoprostone is not used to treat preeclampsia. Option C is incorrect as dinoprostone causes uterine contractions rather than relaxation. Option D is incorrect as dinoprostone is not used to treat genital herpes simplex virus.
A charge nurse is teaching a group of staff nurses about fetal monitoring during labor. Which of the following findings should the charge nurse instruct the staff members to report to the provider?
- A. Contraction durations of 95 to 100 seconds
- B. Contraction frequency of 2 to 3 min apart
- C. Absent early deceleration of fetal heart rate
- D. Fetal heart rate is 140/min
Correct Answer: A
Rationale: The correct answer is A: Contraction durations of 95 to 100 seconds. Prolonged contractions can indicate uterine hyperstimulation, leading to decreased fetal oxygenation. Staff should report this to the provider for further evaluation and management.
Explanation:
1. Contraction durations of 95 to 100 seconds are prolonged and may indicate uterine hyperstimulation, potentially compromising fetal oxygenation.
2. Reporting this finding to the provider allows for timely intervention to prevent fetal distress.
3. Choices B, C, and D do not directly indicate a concern for fetal well-being during labor and would not require immediate reporting to the provider.