Nokea
The client admitted in preterm labor is told that an amniocentesis needs to be performed. The client asks the nurse why this is necessary when the HCP has been performing ultrasounds throughout the pregnancy. Which is an appropriate response by the nurse?
- A. “Your baby is older now, and an amniocentesis provides us with more information on how your baby is doing.”
- B. “An amniocentesis could not be Performed before 32 weeks, so you will be having this test from now until delivery.”
- C. “Your doctor wants to make sure that there are no problems with the baby that an ultrasound might not be able to identify.”
- D. “With your preterm labor your doctor needs to know your baby’s lung maturity; this is best identified by amniocentesis.”
Correct Answer: D
Rationale: The amniocentesis is being performed to determine fetal lung maturity. Once fetal lung maturity is determined, appropriate care can be planned, including administration of betamethasone, administration of tocolytics, or delivery of the baby. While an amniocentesis can provide fetal information that an ultrasound cannot, the rationale for the amniocentesis is to determine lung maturity. Stating additional information is too broad. An amniocentesis can be performed as early as 12 weeks’ gestation, not after 32 weeks. The amniocentesis is not being performed to identify fetal anomalies.
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Which statement made by a participant indicates the need for additional teaching regarding management of urinary frequency?
- A. Limiting fluid intake will help control this problem.
- B. I should report a burning sensation during urination.
- C. Urinating before going to bed may help control this problem.
- D. Avoiding caffeinated beverages may help control the problem.
Correct Answer: A
Rationale: Limiting fluid intake is not recommended, as hydration is essential; the other statements reflect appropriate management strategies.
The 38-year-old pregnant client at 22 weeks’ gestation has just been told she has hydramnios after undergoing a sonogram for size greater than dates. The nurse should further assess for which conditions associated with hydramnios? Select all that apply.
- A. A congenital anomaly
- B. Gestational diabetes
- C. Chronic hypertension
- D. TORCH infections
- E. Preeclampsia
Correct Answer: A,B,D
Rationale: In cases of anencephaly, the fetus is thought to urinate excessively because of overstimulation of the cerebrospinal centers, resulting in hydramnios. The nurse should further assess for gestational diabetes. Hydramnios is thought to occur from excessive fetal urination due to fetal hyperglycemia. Infants with mothers infected with toxoplasmosis, rubella, CMV, or herpes simplex virus infections (TORCH) are more likely to have hydramnios due to the inflammatory response and fluid accumulation. Chronic hypertension is not associated with excess amniotic fluid. Preeclampsia is not associated with excess amniotic fluid.
The nurse observes on the monitor tracing of the client in the transition phase of labor that the baseline FHR is 160 and that there is moderate variability with V-shaped decelerations unrelated to contractions. What should the nurse do first?
- A. Prepare for delivery.
- B. Notify the obstetrician.
- C. Apply oxygen nasally.
- D. Reposition the client.
Correct Answer: D
Rationale: Repositioning the client to her side or to knee-chest should be done first to take the pressure off the umbilical cord. Variable decelerations usually result from cord compression and stretching during fetal descent. The fetus has a normal baseline HR and good variability. There is no indication that immediate delivery is necessary. Other measures could correct the V-shaped (variable) decelerations. Other nursing measures are used to correct the V-shaped (variable) decelerations prior to contacting the obstetrician (or midwife). Repositioning the client should be implemented prior to giving her oxygen.
Which fetal heart rate must the nurse report immediately to the physician?
- A. 100 beats/minute
- B. 120 beats/minute
- C. 140 beats/minute
- D. 160 beats/minute
Correct Answer: A
Rationale: A fetal heart rate of 100 beats/minute is below the normal range (110-160 bpm) and may indicate fetal distress, requiring immediate reporting.
Which newborn behavior is normal and does not require immediate concern?
- A. Frequent hiccups
- B. Persistent vomiting
- C. Lethargy for days
- D. High fever
Correct Answer: A
Rationale: Frequent hiccups are normal in newborns and typically resolve without intervention, unlike the other symptoms.