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The nurse is assessing a client in labor and notes persistent late decelerations on the monitor. What is the priority action?
- A. Reposition the client to her left side.
- B. Administer oxygen via face mask.
- C. Increase IV fluids.
- D. Notify the healthcare provider.
Correct Answer: A
Rationale: The correct answer is A: Reposition the client to her left side. This is the priority action because late decelerations indicate uteroplacental insufficiency, possibly due to compression of the umbilical cord. Repositioning the client to her left side can help improve blood flow to the placenta by reducing pressure on the vena cava, thus optimizing fetal oxygenation. Administering oxygen (B) is important but not the immediate priority. Increasing IV fluids (C) may not directly address the cause of late decelerations. Notifying the healthcare provider (D) is important but should come after immediate interventions.
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Many teens wait until the second or even third trimester to seek prenatal care. The nurse should understand that the reasons behind this delay include which of the following? (Select all that apply.)
- A. Continuing to deny the pregnancy
- B. Uncertainty about where to go for care
- C. Lack of realization that they are pregnant
- D. A desire to gain control over their situation
Correct Answer: A
Rationale: The correct answer is A: Continuing to deny the pregnancy. This is because some teens may struggle to come to terms with their pregnancy and deny it, leading to delays in seeking prenatal care. The other choices are incorrect. B: Uncertainty about where to go for care is not a common reason for delaying prenatal care as resources and information are usually available. C: Lack of realization that they are pregnant is unlikely as most teens eventually become aware of their pregnancy. D: A desire to gain control over their situation does not usually lead to delaying prenatal care as seeking care is a proactive step towards gaining control.
The nurse understands that many patients who experience violence become homeless to escape their situation. How can the nurse help these patients?
- A. Tell the patient to go back home in order to have a place to live.
- B. Tell the patient to get a job in order to have a place to stay.
- C. Refer the patient to a shelter.
- D. Refer the patient to the police.
Correct Answer: C
Rationale: The correct answer is C: Refer the patient to a shelter. This option is the most appropriate because it addresses the immediate need for a safe place to stay for patients experiencing violence and homelessness. Referring the patient to a shelter provides them with temporary housing, safety, and access to resources and support services. Options A and B are not suitable as they overlook the safety concerns of the patient and may put them at risk of further harm. Option D, referring the patient to the police, may not address the patient's need for shelter and support services. Therefore, option C is the most effective and compassionate way to help patients in this situation.
A client in the second stage of labor reports intense rectal pressure. What does this finding indicate?
- A. The baby is in a breech position.
- B. Cervical dilation is incomplete.
- C. The baby is descending into the birth canal.
- D. Labor contractions are ineffective.
Correct Answer: C
Rationale: Step 1: In the second stage of labor, the baby is descending into the birth canal for delivery.
Step 2: Intense rectal pressure is a common sensation as the baby moves down.
Step 3: This indicates progress in labor as the baby is descending.
Step 4: Choice A is incorrect as breech position presents differently.
Step 5: Choice B is incorrect as incomplete cervical dilation may not cause rectal pressure.
Step 6: Choice D is incorrect as effective labor contractions are needed for descent.
A nurse is teaching a client who is at 41 weeks of gestation about a non-stress test. Which of the following information should the nurse include in the teaching?
- A. "This test will confirm fetal lung maturity ".
- B. "This test will determine adequacy of placental perfusion".
- C. "This test will detect fetal infection".
- D. "This test will predict maternal readiness for labor".
Correct Answer: B
Rationale: The correct answer is B: "This test will determine adequacy of placental perfusion." The non-stress test is used to assess fetal well-being by monitoring fetal heart rate in response to fetal movement. It helps determine if the placenta is providing enough oxygen and nutrients to the fetus. This information is crucial in assessing the overall health and viability of the fetus.
A: "This test will confirm fetal lung maturity" - This statement is incorrect because the non-stress test does not assess fetal lung maturity. That is usually done through tests like amniocentesis.
C: "This test will detect fetal infection" - This statement is incorrect because the non-stress test does not detect fetal infection. Other tests like amniocentesis or blood tests are used for this purpose.
D: "This test will predict maternal readiness for labor" - This statement is incorrect as the non-stress test focuses on fetal well-being and does not predict maternal readiness for labor.
The nurse is performing a prenatal assessment. What finding is considered a positive sign of pregnancy?
- A. Positive pregnancy test.
- B. Auscultation of fetal heart tones.
- C. Hegar's sign.
- D. Chadwick's sign.
Correct Answer: B
Rationale: The correct answer is B, auscultation of fetal heart tones, because it is a definitive sign of pregnancy indicating the presence of a fetus. This can be heard around 10-12 weeks of gestation using a Doppler device. It is a positive sign as it directly confirms the existence of a developing fetus.
A: A positive pregnancy test is a probable sign and can indicate pregnancy but is not definitive.
C: Hegar's sign is a probable sign characterized by softening of the lower uterine segment, not specific to pregnancy.
D: Chadwick's sign is a probable sign of pregnancy indicated by bluish discoloration of the cervix, vagina, and labia, not a definitive sign of pregnancy.