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A primipara patient who is 12 weeks gestation is being scheduled for an abdominal ultrasound. The client asks the nurse why she needs this test. What is the nurse’s best response?
- A. This test is to determine the position of the fetus.
- B. This test is to determine if there is enough amniotic fluid.
- C. This test is to determine how many weeks gestation you are.
- D. This test is to determine fetal breathing movements.
Correct Answer: C
Rationale: The correct answer is C: This test is to determine how many weeks gestation you are. At 12 weeks gestation, an ultrasound is commonly performed to accurately determine the gestational age of the fetus. This is important for monitoring fetal development and ensuring proper prenatal care.
A: This test is to determine the position of the fetus - Incorrect. The position of the fetus is usually determined in later stages of pregnancy and not the primary objective of an early pregnancy ultrasound.
B: This test is to determine if there is enough amniotic fluid - Incorrect. Amniotic fluid levels are typically assessed in later stages of pregnancy, not at 12 weeks gestation.
D: This test is to determine fetal breathing movements - Incorrect. Fetal breathing movements are typically observed in the third trimester, not at 12 weeks gestation.
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What condition is related to an increased risk for fetal demise?
- A. diabetes
- B. migraine headache
- C. spina bifida
- D. thyroid disorder
Correct Answer: A
Rationale: The correct answer is A: diabetes. Diabetes is associated with an increased risk of fetal demise due to complications such as congenital anomalies, macrosomia, and placental insufficiency. High blood sugar levels can lead to adverse effects on the fetus, including stillbirth. Migraine headache (B) and spina bifida (C) are not directly linked to fetal demise. Thyroid disorders (D) can impact pregnancy outcomes but are not specifically associated with an increased risk of fetal demise.
What is a potential complication for the neonate due to precipitous labor?
- A. respiratory distress
- B. low birth weight
- C. prelabor rupture of membranes
- D. placenta previa
Correct Answer: A
Rationale: The correct answer is A: respiratory distress. During precipitous labor, the rapid delivery can cause the neonate to experience respiratory distress due to inadequate time for fluid clearance from the lungs, leading to transient tachypnea or respiratory distress syndrome. This complication can result in difficulty breathing and require immediate medical intervention.
Summary:
B: Low birth weight is not directly associated with precipitous labor.
C: Prelabor rupture of membranes is unrelated to the speed of labor.
D: Placenta previa is a condition involving the placenta's position, not typically related to the duration of labor.
The nurse admits a laboring patient at term. On review of the prenatal record, the patient's pregnancy has been unremarkable and she is considered low risk. In planning the patient's
- A. the fetal heart rate during the first stage of labor?
- B. Every 10 minutes
- C. Every 15 minutes
- D. Every 30 minutes
Correct Answer: C
Rationale: The correct answer is C: Every 15 minutes. This is the appropriate frequency for monitoring the fetal heart rate during the first stage of labor for a low-risk patient. Monitoring every 15 minutes allows for regular assessment of the baby's well-being without being overly invasive. Monitoring every 10 minutes (choice A) would be too frequent and may lead to unnecessary interventions. Monitoring every 30 minutes (choice D) would be too infrequent and could potentially miss important changes in the fetal heart rate. Choice B is not the correct answer because monitoring every 10 minutes is too frequent for a low-risk patient and could lead to unnecessary interventions and increased stress for the laboring patient.
In which situation would a baseline fetal heart rate of 160 to 170 bpm be considered a normal finding?
- A. The fetus is at 30 weeks of gestation.
- B. The mother has a history of fast labors.
- C. The mother has been given an epidural block.
- D. The mother has mild preeclampsia but is not in labor.
Correct Answer: A
Rationale: The correct answer is A because at 30 weeks of gestation, a fetal heart rate of 160 to 170 bpm is considered normal due to the fetus's stage of development. Fetal heart rates gradually decrease as gestation progresses. Choices B, C, and D are incorrect because they do not directly impact the fetal heart rate based on gestational age. Choice B, fast labors, does not affect the baseline fetal heart rate. Choice C, epidural block, may cause maternal hypotension but typically doesn't affect the fetal heart rate. Choice D, mild preeclampsia, may lead to fetal distress but does not directly influence the baseline fetal heart rate.
The nurse is making a plan of care for a patient who is in the first 24-hour period past a cesarean delivery. Which interventions will the nurse include in regards to medications? Select all that apply.
- A. Continue a daily stool softener.
- B. Manage pain with morphine.
- C. Ensure the availability of naloxone.
- D. Provide prophylaxis antibiotics.
Correct Answer: C
Rationale: The correct answer is C: Ensure the availability of naloxone. Naloxone is an opioid antagonist used to reverse the effects of opioid overdose, which could occur if the patient is receiving morphine for pain management post-cesarean delivery. It is essential to have naloxone readily available to counteract any potential opioid-related respiratory depression.
A: Continuing a daily stool softener is not directly related to medications typically given post-cesarean delivery and is not a priority in the immediate post-operative period.
B: Managing pain with morphine is a common practice post-cesarean delivery, but the focus here is on the intervention related to medication safety, which is ensuring naloxone availability.
D: Providing prophylactic antibiotics is important post-cesarean delivery to prevent infection but is not directly related to medication safety in this scenario.