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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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A client at 40 weeks of gestation is experiencing contractions every 3 to 5 minutes, becoming stronger. A vaginal exam by the registered nurse reveals the client's cervix is 3 cm dilated, 80% effaced, and -1 station. The client requests pain medication. Which of the following actions should the nurse prepare to take? (Select all that apply)
- A. Provide ice chips.
- B. Insert an indwelling urinary catheter.
- C. Administer opioid analgesic medication.
- D. Provide ice chips.
Correct Answer: C
Rationale: The correct action is to administer opioid analgesic medication (Choice C). At 40 weeks gestation with contractions every 3-5 minutes, 3 cm dilated, 80% effaced, and -1 station, the client is in active labor. Pain medication is appropriate to manage discomfort during labor. Opioid analgesics can help reduce pain intensity while still allowing the client to remain alert and participate in labor. Ice chips (Choice A and D) are not directly related to pain management in labor. Inserting a urinary catheter (Choice B) is not indicated unless there are specific concerns about bladder distention.
An adolescent is being taught about levonorgestrel contraception by a school nurse. What information should the nurse include in the teaching?
- A. You should take the medication within 72 hours following unprotected sexual intercourse.
- B. Do not take this medication if you are on an oral contraceptive.
- C. If you do not start your period within 5 days of taking this medication, you will need a pregnancy test.
- D. One dose of this medication will prevent pregnancy for 14 days after taking it.
Correct Answer: A
Rationale: Step 1: Levonorgestrel is a type of emergency contraception that is most effective when taken within 72 hours after unprotected sex.
Step 2: Taking the medication within the specified time frame increases its effectiveness in preventing pregnancy.
Step 3: Thus, the nurse should emphasize to the adolescent the importance of taking the medication promptly after unprotected intercourse.
Step 4: This information is crucial for the adolescent to understand the time-sensitive nature of levonorgestrel contraception.
Summary:
- Choice B is incorrect because it provides contradictory information. Levonorgestrel can be taken even if the individual is on an oral contraceptive.
- Choice C is incorrect as starting a period is not a reliable indicator of pregnancy. A pregnancy test is recommended if there are concerns.
- Choice D is incorrect because levonorgestrel is a single-dose emergency contraception and does not provide protection for 14 days.
A healthcare provider is reinforcing teaching with a client about a new prescription for medroxyprogesterone. Which of the following information should the provider include in the teaching? (Select all that apply)
- A. Weight fluctuations can occur.
- B. Irregular vaginal spotting can occur.
- C. You should increase your intake of calcium.
- D. All of the above
Correct Answer: D
Rationale: The correct answer is D because all options are relevant when teaching a client about medroxyprogesterone. A, weight fluctuations can occur due to hormonal changes. B, irregular vaginal spotting is a common side effect of medroxyprogesterone. C, increasing calcium intake is important to prevent bone density loss associated with long-term medroxyprogesterone use. Therefore, all options are essential for comprehensive client education. Other choices are incorrect because excluding any of these key points could lead to incomplete information and potential misunderstandings regarding the medication's effects and management.
A client at 42 weeks of gestation is having an ultrasound. For which of the following conditions should the nurse prepare for an amnioinfusion? (Select all that apply)
- A. Oligohydramnios
- B. Hydramnios
- C. Fetal cord compression
- D. Polyhydramnios
Correct Answer: A
Rationale: Rationale: A client at 42 weeks of gestation is at risk for oligohydramnios, which is associated with decreased amniotic fluid levels. Amnioinfusion can be used to increase amniotic fluid volume to prevent fetal cord compression and facilitate fetal movement during labor.
Summary:
- B: Hydramnios (excessive amniotic fluid) does not require amnioinfusion.
- C: Fetal cord compression is a reason for amnioinfusion, not a condition to prepare for.
- D: Polyhydramnios (excessive amniotic fluid) does not typically require amnioinfusion unless there are complicating factors.
A client who is at 22 weeks gestation is being educated by a nurse about the amniocentesis procedure. Which of the following statements should the nurse make?
- A. You will lie on your right side during the procedure.
- B. You should not eat anything for 24 hours before the procedure.
- C. You should empty your bladder before the procedure.
- D. The test is performed to determine gestational age.
Correct Answer: C
Rationale: The correct answer is C: You should empty your bladder before the procedure. This is important because a full bladder can obstruct the visualization of the fetus during amniocentesis. By emptying the bladder, the uterus is better positioned for the procedure, making it safer and more effective.
Explanation:
1. A (You will lie on your right side during the procedure) is incorrect because the position during amniocentesis is typically on the back or slightly tilted to the left.
2. B (You should not eat anything for 24 hours before the procedure) is incorrect as fasting is not required for amniocentesis.
3. D (The test is performed to determine gestational age) is incorrect as amniocentesis is used to detect genetic abnormalities, not gestational age.