Nokea
The nurse admits a laboring patient at term. On review of the prenatal record, the patient's pregnancy has been unremarkable and she is considered low risk. In planning the patient's
- A. the fetal heart rate during the first stage of labor?
- B. Every 10 minutes
- C. Every 15 minutes
- D. Every 30 minutes
Correct Answer: C
Rationale: The correct answer is C: Every 15 minutes. This is the appropriate frequency for monitoring the fetal heart rate during the first stage of labor for a low-risk patient. Monitoring every 15 minutes allows for regular assessment of the baby's well-being without being overly invasive. Monitoring every 10 minutes (choice A) would be too frequent and may lead to unnecessary interventions. Monitoring every 30 minutes (choice D) would be too infrequent and could potentially miss important changes in the fetal heart rate. Choice B is not the correct answer because monitoring every 10 minutes is too frequent for a low-risk patient and could lead to unnecessary interventions and increased stress for the laboring patient.
You may also like to solve these questions
The nurses in a labor and delivery unit are concerned about the high incidence of cesarean deliveries at their facility and initiate an internal study. Which is the most likely condition the nurses will recognize as a contributor to the rate of cesarean births?
- A. The facility has a high rating for managing high-risk pregnancies.
- B. Policies and parameters for cesarean need to be reviewed and refined.
- C. Community education about the advantages of vaginal birth is deficient.
- D. The incidence of maternal requests for cesarean delivery is increasing.
Correct Answer: D
Rationale: Step 1: Maternal requests for cesarean delivery are a significant contributor to the high incidence of cesarean births.
Step 2: Maternal requests may stem from various factors such as fear of labor pain, convenience, or personal preferences.
Step 3: Nurses can address this issue by educating women on the risks and benefits of cesarean versus vaginal delivery.
Step 4: By understanding and addressing maternal requests, the facility can potentially lower the cesarean delivery rate.
Summary:
- Choice A is incorrect as high-risk pregnancies do not directly contribute to the rate of cesarean births.
- Choice B is incorrect as reviewing cesarean policies alone may not address the underlying issue of maternal requests.
- Choice C is incorrect as community education, while important, may not directly impact the rate of cesarean deliveries as compared to addressing maternal requests.
What is a potential complication for the neonate due to precipitous labor?
- A. respiratory distress
- B. low birth weight
- C. prelabor rupture of membranes
- D. placenta previa
Correct Answer: A
Rationale: The correct answer is A: respiratory distress. During precipitous labor, the rapid delivery can cause the neonate to experience respiratory distress due to inadequate time for fluid clearance from the lungs, leading to transient tachypnea or respiratory distress syndrome. This complication can result in difficulty breathing and require immediate medical intervention.
Summary:
B: Low birth weight is not directly associated with precipitous labor.
C: Prelabor rupture of membranes is unrelated to the speed of labor.
D: Placenta previa is a condition involving the placenta's position, not typically related to the duration of labor.
The nurse is educating a primigravida patient about prenatal testing/screening. She inquires why she needs to be tested for HIV. Which of the following is the nurse’s best response?
- A. It is a recommended screening for all women, regardless of risk factors.
- B. It is a recommended screening for a woman who is not married.
- C. It is a recommended screening for a woman who has had gonorrhea.
- D. It is a recommended screening for a woman who has had more than one sexual partner.
Correct Answer: A
Rationale: The correct answer is A: It is a recommended screening for all women, regardless of risk factors. This is because HIV screening during pregnancy is essential to prevent mother-to-child transmission. HIV can be asymptomatic, so screening all pregnant women is crucial. Options B, C, and D are incorrect because marital status, history of gonorrhea, or number of sexual partners do not determine the need for HIV screening during pregnancy. HIV screening is recommended universally to ensure the health of both the mother and the baby.
What condition do restlessness, cyanosis, nasal flaring, orthopnea, and use of accessory muscles indicate?
- A. liver failure
- B. alteration in oxygenation
- C. preterm delivery
- D. gestational diabetes
Correct Answer: A
Rationale: The correct answer is B: alteration in oxygenation. Restlessness, cyanosis, nasal flaring, orthopnea, and the use of accessory muscles are all classic signs of respiratory distress, indicating a problem with oxygenation. Liver failure (A) would typically present with jaundice, ascites, and coagulopathy, not respiratory symptoms. Preterm delivery (C) is related to early labor signs, such as contractions and cervical changes. Gestational diabetes (D) would manifest with symptoms like increased thirst, frequent urination, and fatigue, not respiratory distress.
A primipara patient who is 12 weeks gestation is being scheduled for an abdominal ultrasound. The client asks the nurse why she needs this test. What is the nurse’s best response?
- A. This test is to determine the position of the fetus.
- B. This test is to determine if there is enough amniotic fluid.
- C. This test is to determine how many weeks gestation you are.
- D. This test is to determine fetal breathing movements.
Correct Answer: C
Rationale: The correct answer is C: This test is to determine how many weeks gestation you are. At 12 weeks gestation, an ultrasound is commonly performed to accurately determine the gestational age of the fetus. This is important for monitoring fetal development and ensuring proper prenatal care.
A: This test is to determine the position of the fetus - Incorrect. The position of the fetus is usually determined in later stages of pregnancy and not the primary objective of an early pregnancy ultrasound.
B: This test is to determine if there is enough amniotic fluid - Incorrect. Amniotic fluid levels are typically assessed in later stages of pregnancy, not at 12 weeks gestation.
D: This test is to determine fetal breathing movements - Incorrect. Fetal breathing movements are typically observed in the third trimester, not at 12 weeks gestation.