Nokea
After an amniotomy, what is the priority nursing action?
- A. Observe color and consistency of fluid
- B. Assess the fetal heart rate pattern
- C. Assess the client's temperature
- D. Evaluate the client for the presence of chills and increased uterine tenderness using palpation
Correct Answer: B
Rationale: The correct answer is B: Assess the fetal heart rate pattern. After an amniotomy (breaking of the water), the priority is to monitor the fetal well-being to ensure the baby is tolerating the procedure well. Assessing the fetal heart rate pattern helps the nurse determine if the baby is experiencing any distress or changes in oxygenation. This immediate assessment is crucial in identifying any potential complications and taking prompt action.
Observing the color and consistency of fluid (A) is important but not as immediate as assessing the fetal heart rate. Assessing the client's temperature (C) and evaluating for chills and increased uterine tenderness (D) are important but do not address the immediate concern of fetal well-being post-amniotomy.
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A nurse is caring for a preterm newborn who is in an incubator to maintain a neutral thermal environment. The father of the newborn asks the nurse why this is necessary. Which of the following responses should the nurse make?
- A. Preterm newborns have a smaller body surface area than normal newborns.
- B. The added brown fat layer in a preterm newborn reduces his ability to generate heat.
- C. Preterm newborns lack adequate temperature control mechanisms.
- D. The heat in the incubator rapidly dries the sweat of preterm newborns.
Correct Answer: C
Rationale: The correct answer is C because preterm newborns lack adequate temperature control mechanisms. Preterm infants have underdeveloped regulatory systems, making them vulnerable to heat loss or overheating. Maintaining a neutral thermal environment in an incubator helps prevent fluctuations in body temperature.
Choice A is incorrect because surface area alone does not explain the need for a neutral thermal environment. Choice B is incorrect as brown fat actually helps generate heat in newborns. Choice D is incorrect as drying sweat is not the primary reason for using an incubator in preterm newborns.
A client is scheduled for a cesarean birth based on fetal lung maturity. Which finding indicates that the fetal lungs are mature?
- A. Absence of Phosphatidylglycerol (PG)
- B. Biophysical profile score of 8
- C. Lecithin/sphingomyelin (L/S) ratio of 2:1
- D. Reactive nonstress test
Correct Answer: C
Rationale: The correct answer is C: Lecithin/sphingomyelin (L/S) ratio of 2:1. This ratio indicates fetal lung maturity as it signifies adequate production of surfactant in the fetal lungs, essential for proper lung function after birth. Absence of Phosphatidylglycerol (PG) (Choice A) indicates immaturity, Biophysical profile score of 8 (Choice B) assesses overall fetal well-being, not lung maturity, and Reactive nonstress test (Choice D) evaluates fetal well-being, not lung maturity. The L/S ratio of 2:1 is the most reliable indicator of fetal lung maturity.
A client who is postpartum received methylergonovine. Which of the following findings indicates that the medication was effective?
- A. Increase in blood pressure
- B. Fundus firm to palpation
- C. Increase in lochia
- D. Report of absent breast pain
Correct Answer: B
Rationale: The correct answer is B: Fundus firm to palpation. Methylergonovine is a medication used to promote uterine contraction, which helps the uterus return to its pre-pregnancy size and prevent postpartum hemorrhage. When the fundus is firm to palpation, it indicates that the uterus is contracting effectively, which is the desired outcome of giving methylergonovine.
A: Increase in blood pressure is not a direct indicator of the medication's effectiveness in this context.
C: Increase in lochia may be a sign of uterine involution but does not directly correlate with the effectiveness of methylergonovine.
D: Reporting of absent breast pain is not a specific indicator of the medication's effectiveness related to uterine contraction.
A nurse is caring for several clients. The nurse should recognize that it is safe to administer tocolytic therapy to which of the following clients?
- A. A client who is experiencing fetal death at 32 weeks of gestation
- B. A client who is experiencing preterm labor at 26 weeks of gestation
- C. A client who is experiencing Braxton-Hicks contractions at 36 weeks of gestation
- D. A client who has a post-term pregnancy at 42 weeks of gestation
Correct Answer: B
Rationale: Correct Answer: B
Rationale:
1. Tocolytic therapy is used to delay preterm labor and prevent premature birth.
2. Administering tocolytic therapy at 26 weeks of gestation allows time for corticosteroids to enhance fetal lung maturity.
3. Delaying labor at this stage can improve neonatal outcomes.
4. Other choices are incorrect because tocolytic therapy is not indicated for fetal death, Braxton-Hicks contractions, or post-term pregnancy.
A client in active labor is being prepared for epidural analgesia. Which of the following actions should the nurse take?
- A. Have the client sit upright on the bed with legs crossed.
- B. Administer a 500 mL bolus of lactated Ringer's solution prior to induction.
- C. Inform the client that the anesthetic effect will last for approximately 2 hours.
- D. Obtain a 30-minute electronic fetal monitoring (EFM) strip prior to induction.
Correct Answer: D
Rationale: The correct answer is D: Obtain a 30-minute electronic fetal monitoring (EFM) strip prior to induction. This is important to assess the fetal well-being and baseline status before initiating epidural analgesia. It helps in detecting any fetal distress or abnormalities that may be exacerbated by the epidural.
A: Having the client sit upright with legs crossed is not recommended as it may interfere with the procedure and comfort of the client.
B: Administering a 500 mL bolus of lactated Ringer's solution is not directly related to preparing for epidural analgesia.
C: Informing the client about the duration of anesthetic effect is important, but ensuring fetal well-being through EFM monitoring is a priority before the procedure.