A client who is at 39 weeks of gestation and is in active labor has fetal heart tones located above the umbilicus at midline. The fetus is likely in which of the following positions?
- A. Cephalic
- B. Transverse
- C. Posterior
- D. Frank breech
Correct Answer: D
Rationale: The correct answer is D: Frank breech. In a frank breech position, the buttocks of the fetus are presenting first, which is why the fetal heart tones can be heard above the umbilicus at midline. In this position, the feet are near the head, causing the buttocks to be the presenting part. Choices A, B, and C are incorrect because in a cephalic position, the head would be presenting, in a transverse position, the baby would be lying sideways, and in a posterior position, the baby's back would be against the mother's back.
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A client who is 6 hours postpartum and Rh-negative has an Rh-positive newborn. The client asks why an indirect Coombs test was ordered. Which of the following is an appropriate response by the healthcare provider?
- A. It determines if kernicterus will occur in the newborn.
- B. It detects Rh-negative antibodies in the newborn's blood.
- C. It detects Rh-positive antibodies in the mother's blood.
- D. It determines the presence of maternal antibodies in the newborn's blood.
Correct Answer: C
Rationale: The correct answer is C because the indirect Coombs test is used to detect Rh-positive antibodies in the mother's blood. In this scenario, the mother is Rh-negative, so if she has been sensitized to Rh-positive blood during childbirth, her immune system may produce antibodies that could potentially harm future Rh-positive pregnancies. This test helps identify the presence of these antibodies early on so appropriate interventions can be initiated to prevent hemolytic disease of the newborn.
Choices A, B, and D are incorrect:
A: This test does not determine if kernicterus will occur in the newborn. Kernicterus is a severe complication of jaundice, which may result from hemolytic disease of the newborn if untreated.
B: The indirect Coombs test does not detect Rh-negative antibodies in the newborn's blood. It specifically looks for Rh-positive antibodies in the mother's blood.
D: The test does not determine the presence of maternal antibodies in the newborn's blood. It focuses on detecting antibodies in
A healthcare professional is assessing a newborn immediately following a scheduled cesarean delivery. Which of the following assessments is the healthcare professional's priority?
- A. Respiratory distress
- B. Hypothermia
- C. Accidental lacerations
- D. Acrocyanosis
Correct Answer: A
Rationale: The correct answer is A: Respiratory distress. This is the priority assessment because a newborn's ability to breathe is crucial for survival. Immediate evaluation of respiratory status is essential to ensure the baby is receiving adequate oxygenation. Hypothermia (choice B) can be addressed after addressing any respiratory issues. Accidental lacerations (choice C) are important but not as immediately life-threatening as respiratory distress. Acrocyanosis (choice D) is a common finding in newborns and does not require immediate intervention unless associated with other concerning symptoms.
A patient on the labor and delivery unit is having induction of labor with oxytocin administered through a secondary IV line. Uterine contractions occur every 2 minutes, last 90 seconds, and are strong to palpation. The baseline fetal heart rate is 150/min, with uniform decelerations beginning at the peak of the contraction and a return to baseline after the contraction is over. Which of the following actions should the nurse take?
- A. Decrease the rate of infusion of the maintenance IV solution.
- B. Discontinue the infusion of the IV oxytocin.
- C. Increase the rate of infusion of the IV oxytocin.
- D. Slow the client's breathing rate.
Correct Answer: B
Rationale: The correct answer is B: Discontinue the infusion of the IV oxytocin. Decelerations starting at the peak of contractions indicate uteroplacental insufficiency, which can be caused by hyperstimulation from oxytocin. Stopping the oxytocin infusion will help alleviate this issue and improve fetal oxygenation. Choice A would not address the underlying cause of the decelerations. Choice C would worsen the hyperstimulation. Choice D is not directly related to the fetal heart rate decelerations.
A client in labor is having contractions 4 minutes apart. Which of the following patterns should the nurse expect on the fetal monitoring tracing?
- A. Contractions that last for 60 seconds each with a 4-minute rest between contractions
- B. A contraction that lasts 4 minutes followed by a period of relaxation
- C. Contractions that last for 60 seconds each with a 3-minute rest between contractions
- D. Contractions that last 45 seconds each with a 3-minute rest between contractions
Correct Answer: C
Rationale: The correct answer is C: Contractions that last for 60 seconds each with a 3-minute rest between contractions. In active labor, contractions typically last around 60 seconds each and occur about 2-5 minutes apart. With contractions 4 minutes apart, a 3-minute rest between contractions aligns with the expected pattern. Choice A is incorrect as the rest between contractions is too long. Choice B is incorrect as a contraction lasting 4 minutes is not typical in labor. Choice D is incorrect as the duration of contractions is shorter than expected in active labor. Therefore, Choice C is the most fitting pattern based on the frequency and duration of contractions during labor.
A nurse in a prenatal clinic overhears a newly licensed nurse discussing conception with a client. Which of the following statements by the newly licensed nurse requires intervention by the nurse?
- A. Fertilization takes place in the outer third of the fallopian tube.
- B. Implantation occurs between 6 to 10 days after conception.
- C. Sperm remain viable in the woman's reproductive tract for 2 to 3 days.
- D. Bleeding or spotting can accompany implantation.
Correct Answer: B
Rationale: The correct answer is B because implantation actually occurs around 6-10 days after fertilization, not after conception. This is a critical distinction as conception refers to the union of sperm and egg to form a zygote, while fertilization specifically refers to the fusion of the genetic material. Therefore, the statement by the newly licensed nurse is inaccurate and requires intervention.
A: Fertilization typically occurs in the outer third of the fallopian tube, making this statement correct.
C: Sperm can indeed remain viable in the woman's reproductive tract for 2 to 3 days, indicating this statement is accurate.
D: Bleeding or spotting can indeed accompany implantation, making this statement correct.
In summary, choice B is incorrect because implantation occurs around 6-10 days after fertilization, not conception. Choices A, C, and D are all correct statements related to conception and fertilization.