Nokea
A primigravid client with insulin-dependent diabetes tells the nurse that the contraction stress test performed earlier in the day was suspicious. The nurse interprets this test result as indicating that the fetal heart rate pattern showed which of the following?
- A. Frequent late decelerations.
- B. Decreased fetal movement.
- C. Inconsistent late decelerations.
- D. Lack of fetal movement.
Correct Answer: C
Rationale: Suspicious results indicate inconsistent late decelerations.
You may also like to solve these questions
The nurse is caring for a primigravid client in active labor who has had two fetal blood samplings to check for fetal hypoxia. The nurse determines that the fetus is showing signs of acidosis when the scalp blood pH is below which of the following?
- A. 7.5.
- B. 7.4.
- C. 7.3.
- D. 7.2.
Correct Answer: D
Rationale: A fetal scalp blood pH below 7.2 indicates acidosis, suggesting fetal hypoxia and the need for intervention. Values above 7.25 are typically reassuring, and 7.2–7.25 may warrant close monitoring.
A client who is planning a pregnancy asks the nurse about the use of herbal supplements to enhance fertility. Which of the following responses by the nurse is most appropriate?
- A. Herbal supplements are safe and effective for enhancing fertility.
- B. Consult with your health care provider before taking any herbal supplements.
- C. Herbal supplements can replace prenatal vitamins during pregnancy.
- D. Most herbal supplements are regulated by the FDA for safety.
Correct Answer: B
Rationale: Herbal supplements can interact with medications or affect pregnancy, so consulting a healthcare provider is essential. They are not proven safe or effective for fertility, not a substitute for prenatal vitamins, and are not tightly regulated by the FDA.
A newly delivered primiparous client asks the nurse, "Can my baby see?" Which of the following statements about neonatal vision should the nurse include in the explanation?
- A. Neonates primarily focus on moving objects.
- B. They can see objects up to 12 inches away.
- C. Usually they see clearly by about 2 days after birth.
- D. Neonates primarily distinguish light from dark.
Correct Answer: B
Rationale: Neonates can focus on objects about 8-12 inches away, which is optimal for bonding during feeding.
When performing Leopold’s maneuvers on a primigravid client, the nurse is palpating the uterus as shown below. Which of the following maneuvers is the nurse performing?
- A. First maneuver
- B. Second maneuver.
- C. Third maneuver.
- D. Fourth maneuver.
Correct Answer: C
Rationale: The third Leopold’s maneuver is performed to: Identify the fetal part that is lying just above the inlet of the true pelvis (i.e., what part is presenting). It helps determine if the presenting part (usually the head or buttocks) is engaged, floating, or movable.
A multigravida in active labor is 7 cm dilated. The fetal heart rate baseline is 130 bpm with moderate variability. The client begins to have variable decelerations to 100 to 110 bpm. What should the nurse do next?
- A. Perform a vaginal examination.
- B. Notify the physician of the decelerations.
- C. Reposition the client and continue to evaluate the tracing.
- D. Administer oxygen via mask at 2 L/minute.
Correct Answer: C
Rationale: Variable decelerations suggest possible cord compression. Repositioning the client (e.g., to a side-lying position) can relieve pressure on the cord, and continued monitoring assesses the effectiveness. Vaginal examination, notification, or oxygen may follow if the issue persists.