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The labor nurse is admitting a patient in active labor with a history of genital herpes. On assessment, the patient reports a recent outbreak, and the nurse verifies lesions on the perineum. What is the nurse"™s next action?
- A. Ask the patient when she last had anything to eat or drink.
- B. Take a culture of the lesions to verify the involved organism.
- C. Ask the patient if she has had unprotected sex since her outbreak.
- D. Use electronic fetal surveillance to determine a baseline fetal heart rate.
Correct Answer: A
Rationale: The correct answer is A: Ask the patient when she last had anything to eat or drink. This is the correct action because the patient is in active labor with genital herpes lesions. Knowing the last time the patient had anything to eat or drink is essential in case an emergency cesarean section is needed, as the patient may need to be NPO.
Option B: Taking a culture of the lesions is not the immediate priority as the patient is in active labor and the presence of lesions is already confirmed.
Option C: Asking about unprotected sex is important for history taking but not the immediate next action in this scenario.
Option D: Using electronic fetal surveillance is also important, but the priority in this case is assessing the patient's fasting status for potential emergency procedures.
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A patient with preeclampsia is admitted complaining of pounding headache, visual changes, and epigastric pain. Nursing care is based on the knowledge that these signs indicate
- A. gastrointestinal upset.
- B. effects of magnesium sulfate.
- C. anxiety caused by hospitalization.
- D. worsening disease and impending convulsion.
Correct Answer: D
Rationale: The correct answer is D because the symptoms described (headache, visual changes, epigastric pain) are classic signs of worsening preeclampsia, indicating impending eclampsia with seizures. This requires urgent intervention to prevent serious complications. Option A is incorrect as gastrointestinal upset does not typically present with these specific signs. Option B is incorrect as magnesium sulfate is used to prevent seizures in preeclampsia, not cause the symptoms described. Option C is incorrect as anxiety would not cause the specific symptoms mentioned. In summary, the signs described point towards worsening disease and the likelihood of impending convulsions, necessitating immediate medical attention.
Which intervention would the nurse initiate when a fetal heart pattern signifying uteroplacental insufficiency occurs?
- A. Inserting a urinary catheter
- B. Administering oxygen by means of nasal cannula
- C. Helping the client turn to the side-lying position
- D. Encouraging the client to pant with her next contraction
Correct Answer: C
Rationale: The correct answer is C: Helping the client turn to the side-lying position. This intervention facilitates increased blood flow to the placenta, improving oxygenation to the fetus during uteroplacental insufficiency. The side-lying position relieves pressure on the vena cava, enhancing blood flow. Inserting a urinary catheter (A) is not indicated for addressing uteroplacental insufficiency. Administering oxygen (B) is important, but turning the client to the side is the priority as it directly improves blood flow. Encouraging panting (D) is not effective in addressing uteroplacental insufficiency.
A high-risk labor patient progresses from preeclampsia to eclampsia. Aggressive management is instituted, and the fetus is delivered via cesarean birth. Which finding in the immediate postoperative period indicates that the patient is at risk of developing HELLP syndrome?
- A. Platelet count of 50,000/mcL
- B. Liver enzyme levels within normal range
- C. Negative for edema
- D. No evidence of nausea or vomiting
Correct Answer: A
Rationale: The correct answer is A: Platelet count of 50,000/mcL. In HELLP syndrome, there is hemolysis, elevated liver enzymes, and low platelet count. A platelet count of 50,000/mcL indicates thrombocytopenia, a key feature of HELLP syndrome. It signifies ongoing coagulation abnormalities and liver dysfunction.
B: Liver enzyme levels within normal range is incorrect as HELLP syndrome typically presents with elevated liver enzymes.
C: Negative for edema is incorrect as edema is not a defining characteristic of HELLP syndrome.
D: No evidence of nausea or vomiting is incorrect as these symptoms are not specific to HELLP syndrome.
What is a common sign or symptom of preeclampsia during pregnancy?
- A. abdominal cramps
- B. severe headache
- C. increased appetite
- D. elevated heart rate
Correct Answer: B
Rationale: The correct answer is B: severe headache. A common sign of preeclampsia is a severe headache due to high blood pressure, a hallmark symptom of the condition. Preeclampsia can lead to dangerous complications for both the mother and the baby. Abdominal cramps (A) are not typically associated with preeclampsia. Increased appetite (C) is not a typical symptom and may even decrease due to other factors. Elevated heart rate (D) is not a specific sign of preeclampsia; high blood pressure is the key indicator.
The nurse applies fetal and uterine monitors to the abdomen of a client in active labor. When the client has contractions, the nurse notes a 15 beats/min deceleration of the fetal heart rate below the baseline lasting 15 seconds. Which is the next nursing action?
- A. Calling the primary health care provider
- B. Changing the maternal position
- C. Obtaining the maternal blood pressure
- D. Preparing the environment for an immediate birth
Correct Answer: B
Rationale: The correct answer is B: Changing the maternal position. Deceleration of fetal heart rate during contractions can indicate umbilical cord compression. Changing the maternal position can relieve pressure on the cord, improving blood flow to the fetus. This action is a non-invasive and immediate intervention that can potentially improve fetal oxygenation. Calling the primary health care provider (A) can be done after addressing the immediate concern. Obtaining maternal blood pressure (C) is not the priority in this situation. Preparing for an immediate birth (D) is premature without first attempting non-invasive interventions.