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A mother is learning how to breastfeed her newborn. tions, moderate variability The lactation nurse is assisting her with this process.
- A. Baseline FHR 140, occasional variable decelera- Which technique is correct? tions, moderate variability
- B. Have the mother stroke the infant's mouth with
- C. Baseline FHR 105, no accelerations, recurrent her nipple so the infant will turn toward the variable decelerations, minimal variability mother's breast for feeding.
- D. Baseline FHR 165, no decelerations, marked
Correct Answer: B
Rationale: Having the mother stroke the infant's mouth with her nipple so the infant will turn toward the mother's breast for feeding is the correct technique when assisting a mother in learning how to breastfeed her newborn. This technique helps stimulate the baby's rooting reflex, which is a natural reflex babies have to turn their head and open their mouth when their cheek is stroked.
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The nurse is educating a client about signs of preterm labor. What symptom should be reported immediately?
- A. Frequent urination.
- B. Low back pain and cramping.
- C. Increased appetite.
- D. Braxton Hicks contractions.
Correct Answer: B
Rationale: Low back pain and cramping can indicate preterm labor and should be reported immediately for further evaluation.
A nurse is caring for a client who is 14 weeks of gestation. At which the following locations should the nurse place the Doppler device when assessing the fetal heart rate?
- A. Midline 2 to 3 cm (0.8 to 1.2 in) above the symphysis pubis
- B. Left Upper Abdomen
- C. Two fingerbreadths above the umbilicus
- D. Lateral at the Xiphoid Process
Correct Answer: A
Rationale: When assessing the fetal heart rate in a client who is 14 weeks of gestation, the nurse should place the Doppler device at the midline 2 to 3 cm above the symphysis pubis. This is the appropriate location for detecting the fetal heartbeat at this gestational age. Placing the Doppler device too high on the abdomen may result in difficulty in detecting the fetal heart rate due to the position of the uterus and fetal size. Placing it too low may not capture the fetal heartbeat accurately. Therefore, the midline location above the symphysis pubis provides the best chance for accurate assessment of the fetal heart rate at 14 weeks of gestation.
A nurse is caring for a client who is gravida 3, para 2, and is in active labor. The fetal head is at 3+ station after a vaginal examination. Which of the following actions should the nurse take
- A. Apply fundal pressure.
- B. Observe for the presence of a nuchal cord.
- C. Observe for crowning.
- D. Prepare to administer oxytocin.
Correct Answer: C
Rationale: Observing for crowning is the appropriate action for the nurse to take when the fetal head is at 3+ station after a vaginal examination. Crowning refers to the appearance of the baby's head at the vaginal opening during delivery. This indicates that the baby is descending and will be born soon. It is important for the nurse to be prepared for the actual birth once crowning is observed, as it signifies that the second stage of labor is progressing and delivery is imminent. Applying fundal pressure, observing for a nuchal cord, or preparing to administer oxytocin are not appropriate actions at this stage of labor when crowning has been observed.
The nurse is caring for a client in the second stage of labor. What finding indicates that birth is imminent?
- A. Cervix is fully dilated.
- B. Contractions every 2 minutes.
- C. Fetal heart rate of 140 beats/minute.
- D. Crowning is observed.
Correct Answer: D
Rationale: Crowning, or the appearance of the fetal head at the vaginal opening, indicates that birth is imminent.
Which component is important to include in the sexual history assessment to assess the risk of sexually transmitted infections (STIs)?
- A. current sexual activity
- B. reproductive plans
- C. education and counseling
- D. history of HIV testing
Correct Answer: A
Rationale: