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At 39-weeks gestation, a multigravida is having a nonstress test (NST), the fetal heart rate (FHR) has remained non-reactive during 30 minutes of evaluation. Based on this finding, which action should the nurse implement?
- A. Initiate an intravenous infusion.
- B. Observe the FHR pattern for 30 more minutes.
- C. Schedule a biophysical profile.
- D. Place an acoustic stimulator on the abdomen.
Correct Answer: D
Rationale: In cases where the fetal heart rate remains non-reactive during an NST, using an acoustic stimulator on the abdomen can help stimulate fetal movement and promote heart rate reactivity. This intervention aims to assess the fetus's well-being and response to external stimuli, which can provide valuable information about fetal health status.
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A client who had her first baby three months ago and is breastfeeding her infant tells the nurse that she is currently using the same diaphragm that she used before becoming pregnant. What information should the nurse provide this client?
- A. Use an alternative form of contraception until a new diaphragm is obtained.
- B. After weaning, the diaphragm should be resized.
- C. Avoid intercourse during ovulation until the diaphragm size is reassessed.
- D. If weight gain during pregnancy was no more than 20 pounds, the diaphragm is safe to use.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Albumin 25% IV is prescribed for a child with nephrotic syndrome. Which assessment finding indicates to the nurse that the medication is having the desired effect?
- A. Weight gain.
- B. Reduction of fever.
- C. Improved caloric intake.
- D. Reduction of edema.
Correct Answer: D
Rationale: The correct answer is D: Reduction of edema. Albumin helps reduce edema by increasing oncotic pressure, drawing fluid back into the blood vessels. In nephrotic syndrome, there is an abnormal loss of protein in the urine, leading to decreased oncotic pressure and fluid shifting into the interstitial spaces, causing edema. Administering albumin helps restore the oncotic pressure, reducing edema, which is a desirable effect of the medication.
The LPN/LVN identifies crepitus when examining the chest of a newborn who was delivered vaginally. Which further assessment should the nurse perform?
- A. Elicit a positive scarf sign on the affected side.
- B. Observe for an asymmetrical Moro (startle) reflex.
- C. Watch for swelling of fingers on the affected side.
- D. Note paralysis of the affected extremity and muscles.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
When teaching a gravid client how to perform kick (fetal movement) counts, which instruction should the nurse include?
- A. If 10 kicks are not felt within one hour, drink orange juice and count for another hour.
- B. Count the movements once daily, for one hour, before breakfast.
- C. Avoid caffeinated drinks for 24 hours before conducting the kick test.
- D. Exercise for 15 minutes before starting the counting to help increase fetal movement.
Correct Answer: A
Rationale: When teaching a gravid client about kick (fetal movement) counts, the nurse should instruct them that if 10 kicks are not felt within one hour, they should drink orange juice and continue counting for another hour. This instruction is crucial as a drop in fetal movements could indicate potential issues with fetal well-being, and taking action such as rechecking after food intake is recommended to monitor the situation closely.
A client at 28 weeks gestation calls the antepartum clinic and reports experiencing a small amount of bright red vaginal bleeding without uterine contractions or abdominal pain. What instruction should the LPN/LVN provide?
- A. Come to the clinic today for an ultrasound.
- B. Go immediately to the emergency room.
- C. Lie on your left side for about one hour and see if the bleeding stops.
- D. Bring a urine specimen to the lab tomorrow to determine if you have a urinary tract infection.
Correct Answer: A
Rationale: Bright red vaginal bleeding without pain could indicate placental issues such as previa. An ultrasound is necessary to evaluate the cause. It is important to rule out potential serious conditions like placental previa, which can lead to further complications for both the mother and the fetus. Therefore, prompt evaluation through an ultrasound at the clinic is essential for appropriate management and ensuring the well-being of the client and her baby.