Nokea
A woman who states that she smokes 2 packs of cigarettes each day is admitted to the labor and delivery suite in labor. The nurse should monitor this labor for which of the following?
- A. Delayed placental separation.
- B. Late decelerations.
- C. Shoulder dystocia.
- D. Precipitous fetal descent.
Correct Answer: B
Rationale: Smoking during pregnancy is associated with placental insufficiency, which can lead to late decelerations in the fetal heart rate.
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The nurse has identified the following nursing diagnosis for a postpartum (PP) client: Potential for fluid volume deficit. Which of the following goals for the mother is appropriate?
- A. Minimal perineal pain.
- B. Normal lochial flow.
- C. Normal temperature.
- D. Weight reduction.
Correct Answer: B
Rationale: Normal lochial flow indicates that the client is not experiencing excessive bleeding, which is a key concern for fluid volume deficit.
The nurse is admitting a client, who reports, 'My water broke yesterday, and I haven't felt my baby move any today.' She is 38 weeks with a history of gestational diabetes. Which assessment data is of most concern to the nurse on admission?
- A. Maternal vital signs: T 100.2, HR 104, RR 20, BP 136/82
- B. Pain score 6/10
- C. Minimal variability and variable decelerations
- D. 5 cm/80% effaced/0 station
Correct Answer: C
Rationale: The correct answer is C because minimal variability and variable decelerations on fetal heart monitoring indicate fetal distress, which is a critical concern. Minimal variability suggests the baby's nervous system is compromised, and decelerations can indicate umbilical cord compression or placental insufficiency, possibly leading to fetal hypoxia. This situation requires immediate intervention to prevent potential harm to the baby.
Choice A is incorrect as the vital signs are slightly elevated but not as concerning as fetal distress. Choice B is incorrect as pain score is subjective and not as critical as fetal well-being. Choice D is incorrect as cervical dilation/effacement/station is important for labor progress but not as concerning as fetal distress in this scenario.
You are performing assessments for an obstetric patient who is 5 months pregnant with her third child. Which finding would cause you to suspect that the patient was at risk?
- A. Patient states that she doesn't feel any Braxton Hicks contractions like she had in her prior pregnancies.
- B. Fundal height is below the umbilicus.
- C. Cervical changes, such as Goodell's sign and Chadwick's sign, are present.
- D. She has increased vaginal secretions.
Correct Answer: B
Rationale: The correct answer is B: Fundal height is below the umbilicus. At 5 months pregnant with her third child, fundal height should be at or above the level of the umbilicus. A fundal height below the umbilicus may indicate intrauterine growth restriction or other fetal growth issues. This finding suggests a potential risk to the pregnancy's progress.
Incorrect Choices:
A: Patient not feeling Braxton Hicks contractions is common and not necessarily indicative of risk.
C: Presence of cervical changes like Goodell's and Chadwick's signs are expected physiological changes in pregnancy and do not necessarily indicate risk.
D: Increased vaginal secretions can be normal during pregnancy and do not necessarily signify a risk.
A woman is in the 'taking-hold phase' of the postpartum period. Which of the following behaviors would the nurse expect to see?
- A. The woman is on the telephone relating her experiences to family and friends.
- B. The woman asks for a meal tray and eats a variety of foods brought from home.
- C. The woman is interested in learning baby-care skills from the nurse.
- D. The woman takes a nap after each breastfeeding and each meal.
Correct Answer: C
Rationale: During the 'taking-hold phase,' the mother is typically eager to learn how to care for her newborn and may seek guidance from the nurse.
A birth plan is being developed by a pregnant couple. Which of the following items should be included in the plan?
- A. The method of infant feeding the mother plans on using.
- B. The name and address of her health care insurance company.
- C. The couple's baby name preferences.
- D. The couple's cell phone numbers.
Correct Answer: A
Rationale: A birth plan typically includes the mother's preferences for labor, delivery, and postpartum care, including infant feeding methods.