Nokea
The nurse has identified the following nursing diagnosis for a postpartum (PP) client: Potential for fluid volume deficit. Which of the following goals for the mother is appropriate?
- A. Minimal perineal pain.
- B. Normal lochial flow.
- C. Normal temperature.
- D. Weight reduction.
Correct Answer: B
Rationale: Normal lochial flow indicates that the client is not experiencing excessive bleeding, which is a key concern for fluid volume deficit.
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The nurse is caring for a client in labor with her third baby. She is 39 weeks gestation, 6 cm dilated, 80% effaced, and 0 station, with minimal variability and recurrent variable decelerations. What action is the highest priority for the nurse?
- A. Administer oxygen
- B. Change maternal position
- C. Perform fetal scalp stimulation
- D. Perform vaginal examination
Correct Answer: B
Rationale: The correct answer is B: Change maternal position. This is the highest priority because the client is experiencing recurrent variable decelerations, which can indicate umbilical cord compression. Changing the maternal position can help relieve the pressure on the cord, potentially improving fetal oxygenation. Administering oxygen (choice A) can be important but addressing the cause of the variable decelerations is crucial. Performing fetal scalp stimulation (choice C) is not appropriate at this time as the focus should be on improving fetal oxygenation. Performing a vaginal examination (choice D) is not necessary at this moment and may even exacerbate the situation.
A nurse is evaluating care based upon the nursing quality indicators. Which areas should the nurse evaluate? (Select all that apply.)
- A. Patient satisfaction level
- B. Hospital readmission rates
- C. Nursing hours per patient day
- D. Patient falls/falls with injuries
Correct Answer: C
Rationale: The American Nurses Association developed the National Database of Nursing Quality Indicators (NDNQI) to measure and evaluate nursing-sensitive outcomes with the purpose of improving patient safety and quality care. Nursing quality indicators include the following: Hospital readmission rates, nursing hours per patient day, and patient falls/falls with injuries. While every major health care organization measures certain aspects of patient satisfaction, it is not a nursing quality indicator.
The nurse has admitted a client who is 30 weeks gestation with suspected intrauterine growth restriction. The physician has ordered a Doppler blood flow study. What does the nurse suspect if the results show an S/D ratio above the 95th percentile for the gestational age, a ratio above 3, or end-diastolic blood flow that is absent or reversed?
- A. Decreased blood pressure
- B. Placental insufficiency
- C. Increased amniotic fluid
- D. Decreased fetal movement
Correct Answer: B
Rationale: The correct answer is B: Placental insufficiency. An elevated S/D ratio (>95th percentile for gestational age or >3) and absent/reversed end-diastolic blood flow on Doppler study indicate impaired placental blood flow, leading to decreased oxygen and nutrient delivery to the fetus. This can result in intrauterine growth restriction (IUGR) and compromise fetal well-being. Decreased blood pressure (A) is not directly related to these Doppler findings. Increased amniotic fluid (C) is more commonly associated with conditions like fetal anomalies or maternal diabetes. Decreased fetal movement (D) may be a sign of fetal distress but is not specifically indicated by Doppler findings in IUGR.
Which complaint made by a patient at 35 weeks of gestation requires additional assessment?
- A. Abdominal pain
- B. Ankle edema in the afternoon
- C. Backache with prolonged standing
- D. Shortness of breath when climbing stairs
Correct Answer: A
Rationale: The correct answer is A: Abdominal pain. This complaint at 35 weeks of gestation requires additional assessment as it could indicate a serious issue such as preterm labor, placental abruption, or other complications. Abdominal pain in late pregnancy should never be ignored. Ankle edema in the afternoon, backache with prolonged standing, and shortness of breath when climbing stairs are common discomforts in pregnancy and may not necessarily indicate a serious problem at this stage.
A 32-week-gravid client presents in the emergency department with severe abdominal pain, rigid abdomen, and scant dark red bleeding. The nurse should assess this client for which of the following?
- A. Signs of pulmonary edema.
- B. Enlarging abdominal girth measurements.
- C. Hyporeflexia and confusion.
- D. Signs of diabetic coma and ketosis.
Correct Answer: B
Rationale: Severe abdominal pain, rigidity, and dark red bleeding could indicate placental abruption, which may cause enlarging abdominal girth due to internal bleeding.