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The nurse is monitoring a client at 39 weeks' gestation receiving oxytocin for labor induction. What finding requires the nurse to stop the infusion?
- A. Contractions every 2–3 minutes.
- B. Contractions lasting 120 seconds.
- C. Baseline fetal heart rate of 140 beats/minute.
- D. Client reports mild back pain.
Correct Answer: B
Rationale: Contractions lasting longer than 90 seconds indicate uterine hyperstimulation and can compromise fetal oxygenation.
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A nurse is assessing a client who is at 37 weeks of gestation. Which of the following statement by the client requires immediate intervention by the nurse?
- A. "It burns when I urinate
- B. "My feet are really swollen today".
- C. "didn't have lunch today, but I have breakfast this morning".
- D. "have been seeing spot this morning"
Correct Answer: D
Rationale: Seeing spots or experiencing visual disturbances can be a sign of preeclampsia, a serious pregnancy complication characterized by high blood pressure. Preeclampsia can lead to severe complications for both the mother and the baby, so it requires immediate intervention by the nurse. The other statements made by the client are concerning but do not indicate an urgent need for intervention compared to the symptoms of preeclampsia.
As a nurse working in a prenatal clinic. It is important to obtain maternal and fetal assessing. While obtaining fetal assessments. Which of the following should the complete for fetal well-being?
- A. Fetal movement, maternal vital signs, maternal weight
- B. Fetal movement, fetal position, fetal weight
- C. Fetal position, fetal heart tone, maternal weight
- D. Fetal heart tones, fetal movement, fundal height
Correct Answer: D
Rationale: When assessing fetal well-being in a prenatal clinic, it is important to focus on factors directly related to the fetus. Fetal heart tones provide crucial information about the baby's heart rate and rhythm, indicating how well the fetus is doing. Fetal movement is another essential indicator of fetal well-being, as it shows signs of good neurological function and reactivity. Finally, measuring fundal height (the distance from the top of the uterus to the pubic bone) helps assess fetal growth and development. These three aspects - fetal heart tones, fetal movement, and fundal height - provide a comprehensive evaluation of the baby's well-being and development during pregnancy.
A nurse is caring for a client who is 4hr postpartum and is experiencing hypovolemic shock. Which of the following actions should the nurse take?
- A. Administer indomethacin
- B. Insert a second using a 22-gauge IV catheter.
- C. Insert an indwelling urinary catheter.
- D. Administer oxygen at 4L/min via nasal cannula.
Correct Answer: B
Rationale: The priority action for a client experiencing hypovolemic shock is to restore circulating volume. Inserting a second IV using a 22-gauge catheter would allow for rapid administration of IV fluids to help restore blood volume and improve circulation. This intervention is crucial in managing hypovolemic shock to prevent further complications and stabilize the client's condition. Administering indomethacin, inserting an indwelling urinary catheter, or administering oxygen, while potentially necessary in some cases, are not the immediate priority in managing hypovolemic shock.
The nurse is conducting a prenatal class on the female reproductive system. When a client asks why the fertilized ovum stays in the fallopian tube for 3 days, what is the best response?
- A. It promotes the fertilized ovum's chances of survival.
- B. It promotes the fertilized ovum's exposure to estrogen and progesterone.
- C. It promotes the fertilized ovum's normal implantation in the top portion of the uterus.
- D. It promotes the fertilized ovum's exposure to luteinizing hormone and follicle-stimulating hormone.
Correct Answer: C
Rationale: The delay ensures the ovum reaches the uterus at the right developmental stage for proper implantation in the upper uterine segment.
A client at 36 weeks' gestation reports decreased fetal movement. What is the nurse's priority action?
- A. Perform a nonstress test.
- B. Encourage the client to drink orange juice.
- C. Schedule an ultrasound.
- D. Notify the healthcare provider.
Correct Answer: A
Rationale: A nonstress test evaluates fetal well-being and is the first step in assessing decreased fetal movement.