Nokea
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.
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A nurse is caring for a client who is in active labor and notes late decelerations in the FRH on the external fetal.... Which of the following actions should the nurse take first?
- A. Change the client's position.
- B. Palpate the uterus to assess for tachysystole.
- C. Increase the client's IV infusion rate.
- D. Administer oxygen at 10 L/min via nonrebreather mask.
Correct Answer: A
Rationale: The correct answer is A: Change the client's position. Late decelerations indicate uteroplacental insufficiency, which can be caused by pressure on the vena cava from the uterus. Changing the client's position can alleviate this pressure, improving fetal oxygenation. Palpating the uterus or increasing IV infusion rate may not address the underlying issue. Administering oxygen is important but should come after addressing the positional issue to ensure optimal oxygen delivery to the fetus.
A client at 35 weeks' gestation reports sharp abdominal pain and vaginal bleeding. What condition should the nurse suspect?
- A. Placenta previa.
- B. Abruptio placentae.
- C. Preterm labor.
- D. Chorioamnionitis.
Correct Answer: B
Rationale: The correct answer is B: Abruptio placentae. This condition presents with sharp abdominal pain and vaginal bleeding, typically occurring in the third trimester. It is caused by the premature separation of the placenta from the uterine wall. The pain is often severe due to the bleeding and can lead to fetal distress. Placenta previa (A) presents with painless vaginal bleeding, preterm labor (C) typically involves regular contractions and cervical changes, and chorioamnionitis (D) is characterized by fever and uterine tenderness.
What hormone is responsible for the development and maturation of the ovarian follicles?
- A. follicle-stimulating hormone (FSH)
- B. luteinizing hormone (LH)
- C. estrogen
- D. progesterone
Correct Answer: A
Rationale: Rationale: Follicle-stimulating hormone (FSH) is responsible for the development and maturation of ovarian follicles by stimulating them to grow and produce estrogen. FSH plays a crucial role in the menstrual cycle and acts on the ovaries to promote follicular development. LH surge triggers ovulation, estrogen is produced by the developing follicles and progesterone is primarily produced after ovulation by the corpus luteum. Therefore, A is correct as it directly influences the growth and maturation of ovarian follicles.
What are signs of neonatal sepsis that a nurse should monitor for?
- A. Tachypnea, poor feeding, and temperature instability
- B. Increased alertness, reduced crying, and stable vitals
- C. Lethargy, poor perfusion, and apnea
- D. Hyperthermia, bradycardia, and cyanosis
Correct Answer: C
Rationale: The correct answer is C because lethargy, poor perfusion, and apnea are classic signs of neonatal sepsis. Lethargy indicates decreased activity and responsiveness, poor perfusion suggests inadequate blood circulation, and apnea is a serious respiratory issue. These signs indicate a systemic infection affecting multiple organs. Choices A, B, and D do not align with typical symptoms of neonatal sepsis. Tachypnea, poor feeding, and temperature instability (Choice A) are more general and can be seen in various conditions. Increased alertness, reduced crying, and stable vitals (Choice B) are not indicative of sepsis, as sepsis typically causes the opposite. Hyperthermia, bradycardia, and cyanosis (Choice D) can be present in sepsis, but they are not as specific or as common as the signs in Choice C.
What is the nurse's first action for a newborn showing signs of hypoglycemia?
- A. Feed the newborn formula immediately
- B. Encourage breastfeeding or formula feeding
- C. Monitor glucose levels every hour
- D. Notify the healthcare provider immediately
Correct Answer: A
Rationale: The correct answer is A: Feed the newborn formula immediately. The first action for a newborn showing signs of hypoglycemia is to provide them with a source of glucose to raise their blood sugar levels quickly. Formula feeding is an effective way to achieve this as it provides a concentrated source of glucose. Encouraging breastfeeding or formula feeding (choice B) is a good option but may not address the immediate need for glucose. Monitoring glucose levels every hour (choice C) is important but not the first action to take in an acute situation. Notifying the healthcare provider immediately (choice D) is necessary but should come after addressing the immediate need for glucose.