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The nurse is monitoring a client in labor with an epidural. What finding requires immediate intervention?
- A. Blood pressure of 100/60 mmHg.
- B. Fetal heart rate of 90 beats/minute.
- C. Client reports warmth in the lower extremities.
- D. Contractions every 5 minutes.
Correct Answer: B
Rationale: The correct answer is B: Fetal heart rate of 90 beats/minute. A fetal heart rate of 90 bpm indicates fetal distress and requires immediate intervention to prevent potential complications. Decreased fetal heart rate can be a sign of fetal hypoxia or distress. The other choices are not as concerning in this context. A blood pressure of 100/60 mmHg is within normal range. The client reporting warmth in the lower extremities is a common side effect of epidural anesthesia. Contractions every 5 minutes may indicate progress in labor but do not require immediate intervention unless associated with fetal distress.
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The nurse is monitoring a client during the first stage of labor. What finding requires immediate intervention?
- A. Contractions every 3–5 minutes.
- B. Baseline fetal heart rate of 110 beats/minute.
- C. Variable decelerations on the fetal monitor.
- D. Client reports back pain during contractions.
Correct Answer: C
Rationale: The correct answer is C because variable decelerations on the fetal monitor indicate umbilical cord compression, which can lead to fetal distress and hypoxia. Immediate intervention is needed to relieve the compression and prevent potential harm to the baby. Contractions every 3-5 minutes (A) are normal in the first stage of labor. A baseline fetal heart rate of 110 beats/minute (B) is within the normal range for a fetus. Client reporting back pain (D) is a common symptom of labor and not necessarily indicative of a complication requiring immediate intervention.
How can a nurse support a mother who has chosen not to breastfeed?
- A. Provide resources on breastfeeding benefits
- B. Provide formula samples for feeding
- C. Discuss the risks of formula feeding
- D. Support the mother’s feeding choice without judgment
Correct Answer: D
Rationale: The correct answer is D because it promotes non-judgmental support for the mother's decision. As a nurse, it is crucial to respect the mother's autonomy and decision-making. Providing resources on breastfeeding benefits (choice A) may come off as pressuring or judgmental. Offering formula samples (choice B) may not align with the mother's choice. Discussing risks of formula feeding (choice C) may create guilt or shame. Supporting the mother's feeding choice without judgment (choice D) encourages a positive and supportive environment for the mother.
The nurse is reviewing lab results for a pregnant client. Which finding is most concerning?
- A. Hemoglobin of 11 g/dL.
- B. WBC count of 14,000 mm3.
- C. Platelet count of 90,000 mm3.
- D. Fasting blood glucose of 90 mg/dL.
Correct Answer: C
Rationale: The correct answer is C: Platelet count of 90,000 mm3. A low platelet count (thrombocytopenia) in pregnancy can lead to serious complications like bleeding disorders or preeclampsia. Hemoglobin level of 11 g/dL is within normal range for pregnancy. WBC count of 14,000 mm3 may indicate infection but is not as concerning as thrombocytopenia. Fasting blood glucose of 90 mg/dL is also normal in pregnancy.
The nurse is teaching a client about preterm labor prevention. What instruction is most appropriate?
- A. Drink at least 8–10 glasses of water daily.
- B. Avoid lying down during the day.
- C. Increase physical activity levels.
- D. Reduce protein intake.
Correct Answer: A
Rationale: The correct answer is A because adequate hydration helps prevent preterm labor by maintaining amniotic fluid levels and preventing dehydration-induced contractions. Drinking 8-10 glasses of water daily ensures proper hydration.
B is incorrect because lying down during the day does not have a direct impact on preterm labor prevention.
C is incorrect as excessive physical activity can sometimes trigger preterm labor instead of preventing it.
D is incorrect as protein intake is important for fetal development and reducing it can lead to nutritional deficiencies, but it is not a direct factor in preventing preterm labor.
Who created the Mongan Method?
- A. physician
- B. midwife
- C. hypnotherapist
- D. organization
Correct Answer: C
Rationale: The correct answer is C: hypnotherapist. The Mongan Method was created by Marie Mongan, who is a hypnotherapist. She developed this method as a childbirth education program that incorporates hypnosis techniques to help women have a more positive and empowering birthing experience. The other choices are incorrect because a physician, midwife, or organization did not create the Mongan Method. Marie Mongan's background in hypnotherapy is the key factor in why choice C is the correct answer.