Maternal Monitoring During Labor ppt

Maternal Monitoring During Labor ppt Related

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A patient who is 38 weeks pregnant presents to the labor and delivery unit. Upon vaginal examination, it is determined the fetus is engaged. What is the correct interpretation by the nurse?

  • A. The cervix is completely effaced.
  • B. The lie is longitudinal.
  • C. The fetal head is flexed.
  • D. The biparietal diameter of the fetal head is at the level of the ischial spines.
Correct Answer: D

Rationale: The correct interpretation by the nurse is D: The biparietal diameter of the fetal head is at the level of the ischial spines. At 38 weeks, engagement indicates the fetal head has descended into the pelvis and reached the level of the ischial spines. This is a crucial landmark in labor progress, indicating descent and readiness for birth. Choices A, B, and C are incorrect. Choice A refers to cervical effacement, which is not related to engagement. Choice B refers to fetal lie, which describes the relationship of the fetal spine to the maternal spine. Choice C refers to fetal head flexion, which is important for the mechanism of labor but not specifically related to engagement.

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A client is 35 weeks’ gestation.

  • A. Nausea and vomiting.
  • B. Maternal ambivalence.
  • C. Fundal height 10 cm above the umbilicus.
  • D. Use of three pillows for sleep comfort.
Correct Answer: D

Rationale: Using multiple pillows for sleep comfort is common in late pregnancy due to discomfort from the growing uterus. Nausea and vomiting are more common in early pregnancy, and maternal ambivalence is not specific to this stage.

What is the term for a nonstress test in which there are two or more fetal heart rate accelerations of 15 or more beats per minute (BPM) with fetal movement in a 20-minute period?

  • A. Positive
  • B. Negative
  • C. Reactive
  • D. Nonreactive
Correct Answer: C

Rationale: A nonstress test is considered reactive when there are at least two accelerations of 15 BPM or more in a 20-minute period, indicating fetal well-being.

The nurse is assessing a pregnant patient who is at 32 weeks gestation and is concerned about leg cramps. Which intervention should the nurse recommend?

  • A. Apply a heating pad to the legs to relieve cramps.
  • B. Perform gentle stretching exercises to reduce muscle tension.
  • C. Increase calcium intake to prevent muscle cramps.
  • D. Lie down and elevate the legs to prevent cramps.
Correct Answer: B

Rationale: The correct answer is B: Perform gentle stretching exercises to reduce muscle tension. Leg cramps during pregnancy are common due to increased weight and pressure on muscles. Gentle stretching exercises can help relieve tension and improve circulation, reducing the likelihood of cramps. Applying heat (choice A) can worsen swelling in pregnancy. Increasing calcium intake (choice C) can help prevent cramps but is not an immediate intervention. Lying down and elevating legs (choice D) can provide temporary relief but may not address the underlying muscle tension.

Which food is the best source of iron?

  • A. Raisins
  • B. Hamburger
  • C. Broccoli
  • D. Molasses
Correct Answer: B

Rationale: Hamburger is rich in heme iron, which is more easily absorbed by the body compared to non-heme sources like raisins or molasses.

A patient who is 38 weeks pregnant reports decreased fetal movement. What should the nurse do next?

  • A. Reassure the patient that decreased fetal movement is normal at this stage
  • B. Perform a nonstress test (NST) to assess fetal well-being
  • C. Administer a tocolytic agent to relieve uterine contractions
  • D. Encourage the patient to drink a sugary drink to stimulate fetal movement
Correct Answer: B

Rationale: The correct answer is B: Perform a nonstress test (NST) to assess fetal well-being.
1. Decreased fetal movement can be a sign of fetal distress.
2. NST helps monitor fetal heart rate and movement to assess fetal well-being.
3. It is a non-invasive and effective way to determine fetal health.
4. Other choices are incorrect:
A: Incorrect because decreased fetal movement is not always normal and should be assessed.
C: Incorrect as tocolytic agents are used to stop preterm labor, not for decreased fetal movement.
D: Incorrect as sugary drinks do not reliably stimulate fetal movement.

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