Nokea
At the last vaginal exam, the client who is in the late first stage of labor was fully effaced, 8 cm dilated, vertex presentation, and station -1. Which observation would indicate that the fetus was in fetal distress?
- A. The fetal heart rate slowly drops to 110 beats/min during strong contractions, recovering to 138 beats/min immediately afterward.
- B. Fresh meconium is found on the examiner's gloved fingers after a vaginal exam, and the fetal monitor pattern remains essentially unchanged.
- C. Fresh, thick meconium is passed with a small gush of liquid, and the fetal monitor shows late decelerations with a variable descending baseline.
- D. The vaginal exam continues to reveal some old meconium staining, and the fetal monitor demonstrates a U-shaped pattern of deceleration during contractions, recovering to a baseline of 140 beats/min.
Correct Answer: C
Rationale: Meconium staining alone is not a sign of fetal distress. Meconium passage is a normal physiological function that is frequently noted with a fetus of more than 38 weeks' gestation. Fresh meconium, in combination with late decelerations and a variable descending baseline, is an ominous signal of fetal distress caused by fetal hypoxia. It is not unusual for the fetal heart rate to drop to less than the 140 to 160 beats/min range in late labor during contractions, and, in a healthy fetus, the fetal heart rate will recover between contractions. Old meconium staining may be the result of a prenatal trauma that is resolved.
You may also like to solve these questions
A client manages peptic ulcer disease (PUD) with excessive amounts of oral antacids. Signs/symptoms of which acid-base imbalance should the nurse assess for?
- A. Metabolic acidosis
- B. Metabolic alkalosis
- C. Respiratory acidosis
- D. Respiratory alkalosis
Correct Answer: B
Rationale: Oral antacids can be effective treatment for PUD when administered properly, but when they are taken in excess they can lead to metabolic alkalosis (a pH of more than 7.45 and a bicarbonate ion [HCO3] level of more than 27 mEq/L [27 mmol/L]). As effective therapy for PUD, antacids bind with the hydrochloric acid (HCl-) of gastric secretions and halt the corrosive action of the HCl-. However, antacids are alkaline substances, and excessive administration can exceed the kidney's ability to clear the excess HCO3, which leads to the accumulation of HCO3, an increased pH, and metabolic alkalosis. Metabolic acidosis occurs when the pH is low and the HCO3 is low; respiratory acidosis occurs when the pH is low and the partial pressure of carbon dioxide (PCO2) is high; and respiratory alkalosis occurs when the pH is high and the PCO2 is low.
The nurse caring for a child diagnosed with kidney disease is analyzing the child's laboratory results and notes a sodium level of 148 mEq/L (148 mmol/L). On the basis of this finding, which clinical manifestation should the nurse expect to note in the child?
- A. Lethargy
- B. Diaphoresis
- C. Cold, wet skin
- D. Dry, sticky mucous membranes
Correct Answer: D
Rationale: Hypernatremia occurs when the sodium level is more than 145 mEq/L (145 mmol/L). Clinical manifestations include intense thirst, oliguria, agitation, restlessness, flushed skin, peripheral and pulmonary edema, dry and sticky mucous membranes, nausea, and vomiting. None of the remaining options are associated with the clinical manifestations of hypernatremia.
A child is admitted to the hospital with a suspected diagnosis of idiopathic thrombocytopenic purpura (ITP) and diagnostic studies are performed. Which diagnostic result is indicative of this disorder?
- A. An elevated platelet count
- B. Elevated hemoglobin and hematocrit levels
- C. Bone marrow exam showing increased megakaryocytes
- D. Bone marrow exam indicating increased immature white blood cells
Correct Answer: C
Rationale: The laboratory manifestations of ITP include the presence of a low platelet count of usually less than 20,000 mm^3 (20 × 10^9/L). Thrombocytopenia is the only laboratory abnormality expected with ITP. If there has been significant blood loss, there is evidence of anemia in the blood cell count. If a bone marrow examination is performed, the results with ITP show a normal or increased number of megakaryocytes, which are the precursors of platelets. Option 4 indicates the bone marrow result that would be found in a child with leukemia.
The nurse is assessing a 39-year-old Caucasian client with a blood pressure (BP) of 152/92 mm Hg at rest, a total cholesterol level of 180 mg/dL (4.5 mmol/L), and a fasting blood glucose level of 90 mg/dL (5.14 mmol/L). On which risk factor for coronary artery disease should the nurse place priority?
- A. Age
- B. Hypertension
- C. Hyperlipidemia
- D. Glucose intolerance
Correct Answer: B
Rationale: Hypertension, cigarette smoking, and hyperlipidemia are major risk modifiable factors for coronary artery disease. Glucose intolerance, obesity, and response to stress are also contributing factors. An age of more than 40 years is a nonmodifiable risk factor. A cholesterol level of 180 mg/dL (4.5 mmol/L) and a blood glucose level of 90 mg/dL (5.14 mmol/L) are within the normal range. The nurse places priority on major risk factors that need modification.
The nurse performs an assessment on a client with a history of heart failure who has been taking diuretics on a long-term basis. The nurse reviews the medication record, knowing that which medication, if prescribed for this client, would place the client at risk for hypokalemia?
- A. Bumetanide
- B. Triamterene
- C. Spironolactone
- D. Hydrochlorothiazide
Correct Answer: A
Rationale: Bumetanide is a loop diuretic. The client on this medication would be at risk for hypokalemia. Triamterene, spironolactone, and hydrochlorothiazide are potassium-retaining diuretics.