Nokea
The nurse is monitoring a pregnant client with suspected gestational hypertension. What finding confirms the diagnosis?
- A. Proteinuria.
- B. Blood pressure of 140/90 mmHg on two occasions.
- C. Edema of the hands and feet.
- D. Elevated blood glucose levels.
Correct Answer: B
Rationale: Gestational hypertension is diagnosed by consistent readings of 140/90 mmHg or higher without proteinuria.
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A newborn is born to a mother with gestational diabetes. What complication is the nurse most likely to monitor for?
- A. Hypoglycemia
- B. Hyperthermia
- C. Jaundice
- D. Respiratory alkalosis
Correct Answer: A
Rationale: Babies of diabetic mothers risk hypoglycemia due to high insulin.
The nurse is educating a client about managing heartburn during pregnancy. What is the best advice?
- A. Lie down immediately after eating.
- B. Eat small, frequent meals.
- C. Drink a glass of water with meals.
- D. Consume spicy foods to aid digestion.
Correct Answer: B
Rationale: Eating small, frequent meals helps prevent reflux and minimizes heartburn during pregnancy.
A nurse is caring for a client who is receiving oxytocin to augment labor. The client has an intrauterine pressure catheter and an internal fetal scalp electrode for monitoring. Which of the following is an indication that the nurse should discontinue the infusion?
- A. Contraction frequency every 3 min
- B. Contraction duration of 100 seconds
- C. Fetal heart rate with moderate
- D. variability Fetal heart rate of 118/min
Correct Answer: B
Rationale: Prolonged contractions lasting more than 90-120 seconds may reduce placental perfusion and oxygenation to the fetus, leading to fetal distress. This can result in fetal hypoxia and compromise. Therefore, if the contraction duration reaches 100 seconds, it is an indication for the nurse to discontinue the oxytocin infusion to prevent harm to the fetus. Monitoring for appropriate contraction duration is crucial to ensure the well-being of both the mother and the fetus during labor. While contraction frequency every 3 minutes, a fetal heart rate with moderate variability, and a fetal heart rate of 118/min can be normal findings during labor, a prolonged contraction duration is a concerning sign that requires immediate intervention.
A woman has been in labor for 16 hours. Her cervix is dilated
- A. The fetal presenting part is not engage
- B. The nurse would expect which malpresentation
- C. CPD (prevents presenting part form becoming engage
Correct Answer: A
Rationale: If a woman has been in labor for 16 hours and her cervix is not dilated, it suggests that the fetal presenting part is not engaged. Engagement refers to the descent of the fetal presenting part (usually the head) into the pelvis. When the presenting part is not engaged, it may lead to a prolonged labor as the fetus needs to descend further for labor to progress effectively. This can result in slower cervical dilation and may require interventions to help facilitate engagement, such as position changes or use of gravity-assisted techniques.
What is the initial action for a mother experiencing severe vaginal bleeding during labor?
- A. Monitor vital signs and provide IV fluids
- B. Position the mother on her left side
- C. Administer oxygen at 10L/min via mask
- D. Prepare for an immediate cesarean section
Correct Answer: C
Rationale: Administering oxygen improves maternal and fetal oxygenation during significant bleeding.