Nokea
The nurse is assessing a client at 20 weeks' gestation with suspected anemia. What lab finding supports this diagnosis?
- A. Hemoglobin of 10 g/dL.
- B. Platelet count of 150,000 mm3.
- C. Hematocrit of 40%.
- D. White blood cell count of 8,000 mm3.
Correct Answer: A
Rationale: A hemoglobin level of 10 g/dL is below normal during pregnancy and indicates anemia.
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The nurse is caring for a client pregnant with twins. Which statement indicates that the client needs additional information?
- A. Because both of my twins are boys, I know that they are identical.
- B. If my twins came from one fertilized egg that split, they are identical.
- C. If I have one boy and one girl, I will know they came from two eggs.
- D. It is rare for both twins to be within the same amniotic sac.
Correct Answer: A
Rationale: The statement 'Because both of my twins are boys, I know that they are identical' is incorrect because twins can be fraternal and of the same sex. Identical twins result from one fertilized egg splitting, while fraternal twins result from two separate fertilized eggs.
The nurse is preparing a postpartum client for discharge. What statement indicates the need for further teaching?
- A. I will avoid heavy lifting for at least 6 weeks.
- B. I can resume sexual activity when I stop bleeding.
- C. I should call my doctor if I experience a fever or foul-smelling discharge.
- D. I will schedule my postpartum visit in 6 weeks.
Correct Answer: B
Rationale: Sexual activity should be resumed based on the healthcare provider's recommendation, not just the cessation of bleeding.
The nurse is performing an assessment on a client who is at 38 weeks' gestation and notes that the fetal heart rate is 174 beats/minute. What is the priority nursing action?
- A. Document the finding.
- B. Check the mother's heart rate.
- C. Notify the health care provider (HCP).
- D. Tell the client that the fetal heart rate is normal.
Correct Answer: C
Rationale: A fetal heart rate above 160 bpm at term may indicate fetal distress, requiring immediate notification of the HCP.
A nurse on the labor and delivery unit is caring for a patient who is having induction of labor with oxytocin administered through a secondary IV line. Uterine contractions occur every 2 min, last 90 sec, and are strong to palpation. The baseline fetal heart rate is 150/min, with uniform decelerations beginning at the peak of the contraction and a return to baseline after the contraction is over. Which of the following actions should the nurse take?
- A. Decrease the rate of infusion of the maintenance IV solution.
- B. Discontinue the infusion of the IV oxytocin.
- C. Increase the rate of infusion of the IV oxytocin.
- D. Slow the client's rate of breathing.
Correct Answer: B
Rationale: The described scenario suggests the presence of late decelerations, which occur when uteroplacental insufficiency leads to decreased fetal oxygenation. In this case, the late decelerations are evident with each contraction, indicating a potential adverse reaction to the oxytocin infusion. The appropriate action would be to discontinue the infusion of IV oxytocin to prevent further compromise to fetal well-being. Alternatively, the nurse should consider repositioning the mother, administering oxygen via a face mask, and notifying the healthcare provider for further assessment and interventions.
The nurse is educating a client about kick counts. When should the client contact the healthcare provider?
- A. Fewer than 10 movements in 2 hours.
- B. Fewer than 5 movements in 1 hour.
- C. No movements after drinking juice.
- D. No movements for 12 hours.
Correct Answer: A
Rationale: Fewer than 10 movements in 2 hours is concerning and warrants further evaluation.