Nokea
The client is hospitalized at 30 weeks’ gestation in preterm labor. A test is performed to determine the lecithin to sphingomyelin (L/S) ratio, with results indicating a ratio less than 2:1. The nurse planning care for the client should expect to implement which interventions? Select all that apply.
- A. Administering hydralazine
- B. Maintaining the client on bedrest
- C. Preparing the client for a nonstress test
- D. Giving betamethasone
- E. Administering metronidazole
Correct Answer: B,C,D
Rationale: Bed rest will maximize placental oxygenation while fetal lung maturity continues. The client should be prepared for a nonstress test. This is used to monitor for uterine contractions and labor. Labor needs to be stopped until the fetal lungs are more fully developed. Betamethasone (Celestone Soluspan) is a corticosteroid and is given to stimulate fetal lung maturity. Hydralazine (Apresoline) is an antihypertensive agent and is administered to clients experiencing preeclampsia, not preterm labor. Metronidazole (Flagyl) is an antiprotozoal and antibacterial agent used to treat a vaginal infection; there is no indication that the client has a vaginal infection.
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The nurse instructs the client to report which newborn symptom immediately?
- A. Mild jaundice on day 3
- B. Inability to suck or feed
- C. Occasional sneezing
- D. Soft spot on head
Correct Answer: B
Rationale: Inability to suck or feed is a serious symptom that may indicate neurological or health issues, requiring immediate reporting.
The laboring client presents with ruptured membranes, frequent contractions, and bloody show. She reports a greenish discharge for 2 days. Place the nurse’s actions in the order that they should be completed.
- A. Perform a sterile vaginal exam
- B. Assess the client thoroughly
- C. Obtain fetal heart tones
- D. Notify the health care provider
Correct Answer: C,A,B,D
Rationale: Obtain FHT should be first. The client has ruptured membranes with greenish fluid, and the fetus could be experiencing nonreassuring fetal status. Perform a sterile vaginal exam to determine labor progression. Assess the client thoroughly. This needs to be completed prior to notifying the HCP with the information. Notify the HCP is last of the options. Assessment findings would need to be reported to the HCP. The client should then be moved into an inpatient room.
Which advice can the nurse give to relieve the client's backache? Select all that apply.
- A. Avoid clothing that fits tightly around the waist.
- B. Sleep on a heating pad.
- C. Take a nonopioid pain reliever regularly.
- D. Wear low-heeled shoes.
- E. Carry objects close to your body.
- F. Squat when picking objects off the floor.
Correct Answer: A,D,E,F
Rationale: Tight clothing, high heels, and improper lifting exacerbate backaches; low-heeled shoes, proper lifting, and loose clothing help relieve strain.
The nurse is doing a one-minute Apgar score on a newborn and tells the parents that it is 7 points. When the parents ask what this means, how should the nurse best respond?
- A. “This score is good, but the baby needs to have a score of 10 in five minutes.”
- B. “The Apgar score can predict intelligence and neurological development.”
- C. “Your baby is fine and should have no difficulty adapting outside the womb.”
- D. “Your baby has good vital signs and is classified as full-term gestational age.”
Correct Answer: C
Rationale: This response is best because a score of 7 to 10 is within a normal range and 并表示新生儿没有任何不适的迹象。A score of 7 to 10 is considered acceptable for a one-minute Apgar. However, when the scoring is repeated at 5 minutes of age, a score of 7 to 10, not just 10, is within normal range. The Apgar score is used to systematically assess an infant at one and five minutes after birth to determine if immediate care is necessary. It is not used to predict intelligence or neurological development. Although the Apgar score does mean that the newborn’s VS are WNL, the Apgar score is not designed to classify gestational age.
The nurse includes which activity to promote bonding with the fetus?
- A. Talking or singing to the fetus
- B. Watching television daily
- C. Avoiding fetal movement monitoring
- D. Limiting prenatal visits
Correct Answer: A
Rationale: Talking or singing to the fetus promotes early bonding and stimulates fetal development.