Nokea
The clinic nurse is obtaining a health history on a newly pregnant patient. Which is an indication for fetal diagnostic procedures if present in the health history?
- A. Maternal diabetes
- B. Weight gain of 25 lb
- C. Maternal age older than 30 years
- D. Previous infant weighing more than 3000 g at birth
Correct Answer: A
Rationale: The correct answer is A, maternal diabetes. Maternal diabetes increases the risk of fetal anomalies, so fetal diagnostic procedures may be indicated for early detection. Weight gain, maternal age over 30, and previous infant weight do not necessarily indicate a need for fetal diagnostic procedures. Weight gain and older age are common in pregnancy, while the previous infant's weight alone is not a direct indicator of fetal health.
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The nurse has received change of shift report on the following four clients. Which of the clients should the nurse assess first?
- A. G1 P0000, 9 weeks’ gestation, hyperemesis gravidarum, vomited twice during the last shift.
- B. G2 P0101, 24 weeks’ gestation, receiving terbutaline po q 2 h for preterm labor, no complaints of cramping during last shift.
- C. G1 P0000, 1 day postpartum, vacuum extraction, for bilateral tubal ligation during this shift.
- D. G2 P0101, 2 days postpartum, spontaneous delivery, had asthma attack during last shift.
Correct Answer: D
Rationale: The client who had an asthma attack during the last shift should be assessed first due to the potential for respiratory complications.
For which patient would an L/S ratio of 2:1 potentially be considered abnormal?
- A. A 38-year-old gravida 2, para 1, who is 38 weeks' gestation
- B. A 24-year-old gravida 1, para 0, who has diabetes
- C. A 44-year-old gravida 6, para 5, who is at term
- D. An 18-year-old gravida 1, para 0, who is in early labor at term
Correct Answer: B
Rationale: The correct answer is B. An L/S ratio of 2:1 is indicative of fetal lung maturity. This means that the lungs of the fetus are likely mature enough to function outside the womb. In choice B, the patient is 24 years old with diabetes, a condition that can affect fetal lung development, making it crucial to assess lung maturity.
Choice A is less likely to have abnormal lung maturity at 38 weeks' gestation. Choice C, a 44-year-old gravida 6, para 5, is more likely to have mature fetal lungs due to multiple pregnancies. Choice D, an 18-year-old in early labor at term, may not necessarily have abnormal lung maturity as she is at term and in labor.
A fetal fibronectin assessment of the cervicovaginal fluids of a 28-week gravida is positive. Based on the results, which of the following complaints should the nurse advise the client to report immediately to the health care provider?
- A. Headache.
- B. Visual disturbances.
- C. Uterine cramping.
- D. Oliguria.
Correct Answer: C
Rationale: Uterine cramping may indicate preterm labor, which is a concern with a positive fetal fibronectin test.
A relaxation technique that can be used during the childbirth experience to decrease maternal pain perception is
- A. using increased environmental stimulation as a method of distraction.
- B. restricting family and friends from visiting during the labor period to keep the patient focused on breathing techniques.
- C. medicating the patient frequently to reduce pain perception.
- D. assisting the patient in breathing methods aimed at taking control of pain perception based on the contraction pattern.
Correct Answer: D
Rationale: Step-by-step rationale for why answer D is correct:
1. Breathing techniques help in managing pain perception during labor.
2. By assisting the patient in breathing methods, she gains control over her pain perception.
3. Controlled breathing can help distract from the intensity of contractions.
4. By focusing on breathing patterns, the patient can stay calm and manage pain effectively.
Summary:
A, B, and C are incorrect because they do not address pain management directly through breathing techniques. Option A relies on distraction, B focuses on isolation rather than coping mechanisms, and C suggests heavy reliance on medication rather than self-control.
What does optimal nursing care after an amniocentesis include?
- A. Pushing fluids by mouth
- B. Monitoring uterine activity
- C. Placing the patient in a supine position for 2 hours
- D. Applying a pressure dressing to the puncture site
Correct Answer: B
Rationale: The correct answer is B: Monitoring uterine activity. After an amniocentesis, it is crucial to monitor uterine activity to detect any signs of preterm labor or uterine contractions. This helps in identifying any potential complications early on and ensures prompt intervention if needed.
A: Pushing fluids by mouth is important for hydration but not directly related to optimal nursing care after an amniocentesis.
C: Placing the patient in a supine position for 2 hours is not recommended as it may increase the risk of hypotension and discomfort for the patient.
D: Applying a pressure dressing to the puncture site is not necessary after an amniocentesis as the risk of bleeding is minimal and pressure dressings may increase the risk of infection.