Nokea
Interventions have been prescribed by the HCP for the client with decreased fetal movement at 35 weeks’ gestation. Place the prescribed interventions in the sequence that they should be performed by the nurse.
- A. Prepare for a nonstress test
- B. Prepare for a biophysical profile
- C. Palpate for fetal movement
- D. Apply and explain the external fetal monitor
Correct Answer: C,D,A,B
Rationale: Palpate for fetal movement should be performed first. Assessment should be first to verify fetal movement. Apply and explain the external fetal monitor should be next. The fetus should be monitored for heart rate changes. Prepare for an NST. The NST is performed to determine fetal well-being. Prepare for a biophysical profile (BPP). The BPP is an assessment of five fetal biophysical variables: FHR acceleration, fetal breathing, fetal movements, fetal tone, and amniotic fluid volume. The first criterion is assessed with the NST. The other variables are assessed by ultrasound scanning.
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The nurse teaches the client to recognize which early labor sign?
- A. Bloody show
- B. Fatigue
- C. Increased appetite
- D. Mild nausea
Correct Answer: A
Rationale: Bloody show, a mucous discharge tinged with blood, is a common early labor sign as the cervix begins to dilate.
The pregnant client has an abnormal 1-hour glucose screen and completes a 3-hour, 100-g oral glucose tolerance test (OGTT). Which test results should the nurse interpret as being abnormal?
- A. Fasting blood glucose = 104 mg/dL
- B. 1-hour = 179 mg/dL
- C. 2-hour = 146 mg/dL
- D. 3-hour = 129 mg/dL
Correct Answer: A
Rationale: The fasting blood glucose of 104 mg/dL is abnormal for the OGTT; normal is 95 mg/dL or lower. A 1-hour OGTT value of 179 mg/dL is normal; normal is 180 mg/dL or lower. The 2-hour OGTT value of 146 mg/dL is normal; an abnormal value is 155 mg/dL or higher. The 3-hour OGTT value of 129 mg/dL is normal; an abnormal value is 140 mg/dL or higher.
The laboring client is experiencing problems, and the nurse is concerned about possible side effects from the epidural anesthetic just administered. Which problems should the nurse attribute to the epidural anesthetic? Select all that apply.
- A. Has breakthrough sharp pain
- B. Blood pressure is increased
- C. Has a pounding headache
- D. Unable to feel a full bladder
- E. Has an elevated temperature
Correct Answer: A,C,D,E
Rationale: Breakthrough pain can occur when the continuous infusion rate of the anesthetic agent is below the recommended rate for a therapeutic dose. Breakthrough pain can also occur when the client has a full bladder or when the cervix is completely dilated. A spinal headache can be a complication of epidural anesthesia and occurs when the dura is accidently punctured during epidural placement. A sensory level of T10 is usually maintained during epidural anesthesia; most women are unable to feel a full bladder or to void after receiving an epidural anesthetic. Maternal temperature may be elevated to 100.1°F (37.8°C) or higher with an epidural. Sympathetic blockade may decrease sweat production and diminish heat loss. Hypertension is a contraindication for epidural anesthesia. A major side effect of epidural anesthesia is hypotension (not hypertension) caused by a spinal blockade, which lowers peripheral resistance, decreases venous return to the heart, and subsequently lessens cardiac output and lowers BP.
The nurse is assessing the postpartum client, who is 5 hours postdelivery. Initially, the nurse is unable to palpate the client’s uterine fundus. Prioritize the nurse’s actions to locate the client’s fundus by placing each step in the correct sequence.
- A. Place the side of one hand just above the client’s symphysis pubis.
- B. Press deeply into the abdomen.
- C. Place the other hand at the level of the umbilicus.
- D. Massage the abdomen in a circular motion.
- E. Position the client in the supine position.
- F. If the fundus is not felt, move the upper hand lower on the abdomen and repeat the massage.
Correct Answer: E,A,C,B,D,F
Rationale: Position the client in supine so the height of the uterus is not influenced by an elevated position. Place the side of one hand just above the client’s symphysis pubis. This supports the lower uterine segment and prevents the inadvertent inversion of the uterus during palpation. Place the other hand at the level of the umbilicus. This is the expected location of the uterine fundus on the day of delivery. Press deeply into the abdomen to allow the massage to reach the fundus. Massage the abdomen in a circular motion. This massage should stimulate the uterus to contract and allow location of the fundus to be determined. If the fundus is not felt, move the upper hand lower on the abdomen and repeat the massage. Involution could potentially be occurring more rapidly than expected if the client is breastfeeding and/or had an uncomplicated labor and birth.
Two days after hospital discharge, the nurse is assessing the mother and her newborn twins in their home. Which statement or question made by the nurse best demonstrates empathy?
- A. “You may be feeling overwhelmed. This is normal.”
- B. “I can’t imagine how tired you must be with twins.”
- C. “How are you feeling about being the mother of twins?”
- D. “I saw that laundry is piling up. Do you want a home aide?”
Correct Answer: C
Rationale: Projecting feelings onto the client does not demonstrate empathy. This statement imposes a personal assumption and does not demonstrate empathy. This question demonstrates empathy. The nurse is asking a question to allow the client to explain her situation and feelings while the nurse listens. The nurse is attempting to understand the experience as lived by the client. Acknowledging that laundry is piling up and offering home aide services do not demonstrate empathy. Commenting on the laundry on the first visit may suggest to the client that she lacks support, and she may be defensive or hurt by the acknowledgement.