Nokea
During an assessment, a client at 26 weeks of gestation presents with which of the following clinical manifestations that should be reported to the provider?
- A. Leukorrhea
- B. Supine hypotension
- C. Periodic numbness of the fingers
- D. Decreased urine output
Correct Answer: D
Rationale: The correct answer is D: Decreased urine output. At 26 weeks of gestation, decreased urine output can be a sign of potential complications like preeclampsia or dehydration, which require immediate medical attention to prevent harm to the mother and baby. Leukorrhea (choice A) is a common pregnancy symptom and not typically concerning. Supine hypotension (choice B) is a known issue in pregnancy but usually occurs later in the third trimester due to pressure on the vena cava when lying on the back. Periodic numbness of the fingers (choice C) can be related to carpal tunnel syndrome, which is common in pregnancy but not typically urgent at 26 weeks unless severe and persistent.
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When discussing intermittent fetal heart monitoring with a newly licensed nurse, which statement should a nurse include?
- A. Count the fetal heart rate for 15 seconds to determine the baseline.
- B. Auscultate the fetal heart rate every 5 minutes during the active phase of the first stage of labor.
- C. Count the fetal heart rate after a contraction to determine baseline changes.
- D. Auscultate the fetal heart rate every 30 minutes during the second stage of labor.
Correct Answer: C
Rationale: The correct answer is C because counting the fetal heart rate after a contraction helps determine baseline changes, which is essential for identifying fetal distress. This method allows for accurate assessment of fetal well-being in response to contractions. Choice A is incorrect as 15 seconds is not enough time to establish a baseline. Choice B is incorrect as auscultating every 5 minutes may not provide timely information during the active phase. Choice D is incorrect because auscultating every 30 minutes in the second stage may miss important changes in fetal status. Therefore, option C is the most appropriate choice for intermittent fetal heart monitoring.
While assisting with the care of a client in active labor, a nurse observes clear fluid and a loop of pulsating umbilical cord outside the client's vagina. Which of the following actions should the nurse perform first?
- A. Place the client in the Trendelenburg position
- B. Apply finger pressure to the presenting part
- C. Administer oxygen at 10 L/min via a non-rebreather
- D. Call for assistance
Correct Answer: D
Rationale: The correct answer is D: Call for assistance. This is the first action the nurse should take in this emergency situation. Calling for help ensures that additional support and resources are available to manage the situation effectively. Placing the client in the Trendelenburg position (A) is not recommended as it can worsen the prolapsed cord. Applying finger pressure to the presenting part (B) can lead to further complications. Administering oxygen (C) may be necessary but is not the priority when a prolapsed cord is present.
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.
During a teaching session with a client in labor, a nurse is explaining episiotomy. Which of the following information should the nurse include?
- A. An episiotomy is a perineal incision made by the provider to facilitate delivery of the fetus
- B. A fourth-degree episiotomy extends into the rectal area and is not recommended
- C. An episiotomy is an incision made by the provider to facilitate delivery of the fetus
- D. A mediolateral episiotomy is preferred over a median episiotomy for most deliveries
Correct Answer: C
Rationale: The correct answer is C because it accurately describes an episiotomy as an incision made by the provider to facilitate delivery of the fetus. This information is crucial for the client to understand the purpose and potential benefits of the procedure.
A: While choice A is similar to the correct answer, it includes unnecessary detail about who makes the incision, which may confuse the client.
B: Choice B is incorrect as it provides inaccurate information about a fourth-degree episiotomy extending into the rectal area, which is not recommended as it would involve cutting through the anal sphincter.
D: Choice D is incorrect because it introduces unnecessary information about the types of episiotomies without providing the basic understanding of what an episiotomy is.
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.