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The continuous electronic FHR monitor tracing on the laboring client is no longer recording. How should the nurse immediately respond?
- A. Conclude that there is a problem with the baby and call for help.
- B. Check that there is adequate gel under the transducer and reposition.
- C. Give the client oxygen via facemask at 8 to 10 liters per minute.
- D. Auscultate fetal heart rate by fetoscope and assess maternal vital signs.
Correct Answer: B
Rationale: When the FHR monitor tracing is no longer recording, the nurse should first check for adequate gel under the transducer. There needs to be adequate gel under the transducer for good conduction, and adding gel frequently corrects the problem. Assessing for adequate gel under the transducer and repositioning should be done before assuming there is a problem with the baby’s HR. There is no indication to give oxygen to the client. Auscultating FHR by fetoscope and assessing maternal VS could be completed, but not until the transducer has been checked.
You may also like to solve these questions
While assessing the prenatal client, the nurse found a number of concerning problems. Place the concerning problems in the sequence that they should be addressed by the nurse.
- A. Currently bleeding and cramping
- B. Previous varicella infection
- C. Currently using tobacco
- D. Has intense pelvic pain
Correct Answer: D,A,C,B
Rationale: Has intense pelvic pain is most concerning and should be addressed first by the nurse. It could be a symptom of a serious medical condition, such as a miscarriage, ectopic pregnancy, or appendicitis. This symptom represents a possible pathology that could warrant immediate surgical intervention. Currently bleeding and cramping should be addressed next. It could be associated with the pelvic pain and could be a symptom of a serious medical condition, such as a miscarriage or ectopic pregnancy. Currently using tobacco can put the client at risk for multiple adverse outcomes and should be addressed, although it is not an immediately concerning factor. Previous varicella infection is important to document but poses no risk to the client or the fetus, so it is the least important to address.
The nurse correctly explains to the group that the most important condition related to frequent urination during pregnancy is related to what factor?
- A. Loss of bladder tone in the mother
- B. The presence of a urinary tract infection
- C. The enlarging uterus exerting pressure on the bladder
- D. The growing fetus excreting increased amounts of waste
Correct Answer: C
Rationale: The enlarging uterus presses on the bladder, causing frequent urination, especially in early and late pregnancy.
The laboring client is requesting IV pain medication instead of epidural anesthesia. The nurse determines that which factor would most definitely contraindicate the administration of nalbuphine hydrochloride?
- A. Completely dilated and 100 percent effaced
- B. Fetal heart rate (FHR) of 120 beats per minute
- C. Reassuring FHR variability and accelerations
- D. Variable decelerations with reassuring FHR
Correct Answer: A
Rationale: Systemic medications, such as nalbuphine hydrochloride (Nubain), should not be administered when advanced dilation is present (transition stage of labor) because its use can lead to respiratory depression if given too close to the time of delivery. An FHR of 120 bpm is within normal parameters of 120 to 160 bpm. Reassuring FHR variability and accelerations are interpreted as adequate placental oxygenation and do not contraindicate administration of nalbuphine hydrochloride. If mild variable decelerations are present but the FHR pattern remains reassuring, nalbuphine hydrochloride can still be administered.
The pregnant client is experiencing low back pain. After determining that the client is not in labor, the nurse instructs the client to perform which exercises to increase comfort and decrease the incidence of the low back pain? Select all that apply.
- A. Kegel exercises
- B. Pelvic tilt exercises
- C. Leg raises
- D. Back stretch
- E. Stepping
Correct Answer: B,C,D
Rationale: Pelvic tilt exercises strengthen and stretch the abdominal and back muscles to relieve pain. Leg raises strengthen and stretch leg and abdominal muscles to relieve pain. Back stretch relieves pain from the back muscles caused by lordosis. Kegel exercises strengthen the pubococcygeal muscle, decreasing urinary leakage, but do not relieve back pain. Stepping provides aerobic exercise, which is good for circulation but is not recommended to decrease low back pain.
Which pregnant client should the nurse encourage to undergo hepatitis B testing?
- A. A client with a history of cigarette smoking
- B. A client who is a health care worker
- C. A client who emigrated in the past year from Haiti
- D. A client who was recently exposed to Haemophilus influenzae
Correct Answer: C
Rationale: Clients from high-prevalence areas like Haiti are at higher risk for hepatitis B, warranting testing during pregnancy.