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During active labor, a nurse notes tachycardia on the external fetal monitor tracing. Which of the following conditions should the nurse identify as a potential cause of the heart rate?
- A. Maternal fever
- B. Fetal heart failure
- C. Maternal hypoglycemia
- D. Fetal head compression
Correct Answer: A
Rationale: The correct answer is A: Maternal fever. Maternal fever can lead to tachycardia in the fetus due to the transfer of maternal antibodies, cytokines, and other inflammatory mediators across the placenta, affecting fetal heart rate. Maternal fever can indicate infection, which can cause fetal distress. The other choices are incorrect because:
B: Fetal heart failure typically presents with bradycardia, not tachycardia.
C: Maternal hypoglycemia can affect the fetus but is more likely to cause fetal bradycardia than tachycardia.
D: Fetal head compression can result in decelerations but not necessarily tachycardia.
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During a weekly prenatal visit, a nurse is assessing a client at 38 weeks of gestation. Which of the following findings should the nurse report to the provider?
- A. Blood pressure 136/88 mm Hg
- B. Report of insomnia
- C. Weight gain of 2.2 kg (4.8 lb)
- D. Report of Braxton-Hicks contractions
Correct Answer: C
Rationale: The correct answer is C: Weight gain of 2.2 kg (4.8 lb). This finding should be reported to the provider because sudden excessive weight gain in late pregnancy can be a sign of preeclampsia, a serious condition characterized by high blood pressure and protein in the urine. This could indicate a potential complication that needs immediate medical attention.
Explanation:
A: Blood pressure 136/88 mm Hg - This blood pressure reading is slightly elevated but not concerning for preeclampsia at this level.
B: Report of insomnia - Insomnia is a common issue during pregnancy and not typically a cause for immediate concern.
D: Report of Braxton-Hicks contractions - Braxton-Hicks contractions are common in the third trimester and are considered normal as long as they are not regular or increasing in intensity.
When a client states, 'My water just broke,' what is the nurse's priority intervention?
- A. Perform Nitrazine testing.
- B. Assess the fluid.
- C. Check cervical dilation.
- D. Begin FHR monitoring.
Correct Answer: D
Rationale: The correct answer is D: Begin FHR monitoring. This is the priority intervention because assessing the fetal heart rate (FHR) helps determine the well-being of the baby after the water breaking. Monitoring the FHR can indicate if the baby is in distress and prompt further actions if needed. Performing Nitrazine testing (choice A) is used to confirm if the fluid is amniotic fluid, but FHR monitoring takes precedence. Assessing the fluid (choice B) is important but not as urgent as monitoring the FHR. Checking cervical dilation (choice C) is not the priority as ensuring the baby's well-being through FHR monitoring is crucial in this situation.
When caring for a client receiving nifedipine for prevention of preterm labor, the nurse should monitor the client for which of the following manifestations?
- A. Blood-tinged sputum
- B. Dizziness
- C. Pallor
- D. Somnolence
Correct Answer: B
Rationale: The correct answer is B: Dizziness. Nifedipine is a calcium channel blocker that can cause hypotension, leading to dizziness. This is a common side effect and needs to be monitored to prevent falls or injury. Blood-tinged sputum (A) is not typically associated with nifedipine use. Pallor (C) is not a common manifestation of nifedipine side effects. Somnolence (D) is also not a common side effect of nifedipine. Dizziness is the most relevant and potentially harmful manifestation to monitor for in a client receiving nifedipine for preterm labor.
A client who is at 24 weeks of gestation is scheduled for a 1-hour glucose tolerance test. Which of the following statements should the nurse include in her teaching?
- A. You will need to drink the glucose solution 1 hour prior to the test.
- B. Limit your carbohydrate intake for 24 hours prior to the test.
- C. A blood glucose of 130 to 140 mg/dL is considered a positive screening result.
- D. You will need to fast for 8 hours prior to the test.
Correct Answer: C
Rationale: The correct answer is C: A blood glucose of 130 to 140 mg/dL is considered a positive screening result. This statement is the correct teaching point because for a 1-hour glucose tolerance test during pregnancy, a blood glucose level of 130-140 mg/dL is considered elevated and may indicate gestational diabetes. The other choices are incorrect: A is wrong because the glucose solution is typically consumed one hour before the test, not prior to the test itself. B is incorrect as limiting carbohydrate intake is not necessary for this test. D is also incorrect because fasting for 8 hours is not required for a 1-hour glucose tolerance test.
A healthcare professional is preparing to collect a blood specimen from a newborn via a heel stick. Which of the following techniques should the professional use to help minimize the pain of the procedure for the newborn?
- A. Apply a cool pack to the heel for 10 minutes prior to the puncture.
- B. Request a prescription for IM analgesic.
- C. Use a manual lancet to pierce the skin.
- D. Place the newborn skin-to-skin on the mother's chest.
Correct Answer: D
Rationale: The correct answer is D: Place the newborn skin-to-skin on the mother's chest. This technique promotes bonding, warmth, and comfort, which can help minimize the newborn's pain perception during the procedure. Skin-to-skin contact releases oxytocin, which has analgesic effects. It also provides emotional support and reduces stress for both the newborn and the mother.
A, applying a cool pack, may cause vasoconstriction and increase pain perception. B, requesting an IM analgesic, is not typically necessary for a routine heel stick and may have potential adverse effects. C, using a manual lancet, does not address the emotional and psychological aspects of pain perception in newborns.