Nokea
The nurse is assessing the client who is 34 weeks’ gestation. Place an X where the nurse should place the Doppler first to assess the FHR when the fetus is thought to be left occiput anterior (LOA).
Correct Answer:
Rationale: FHT are best heard in the lower left quadrant of the client’s abdomen when the fetus is LOA.
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The nurse is taking the health history of the 40-year-old pregnant client. Which identified medical conditions increase the client’s risk for complications during her pregnancy? Select all that apply.
- A. Diabetes mellitus type 2
- B. Previous full-term pregnancy
- C. Controlled chronic hypertension
- D. New onset of iron-deficiency anemia
- E. Hemorrhage with a previous pregnancy
Correct Answer: A,C,D,E
Rationale: DM is a risk factor for complications such as preeclampsia, eclampsia, dystocia, fetal macrosomia, recurrent monilial vaginitis and UTIs, ketoacidosis, congenital abnormalities, and others. Controlled chronic hypertension may become uncontrolled during pregnancy due to water retention and other factors related to pregnancy. It is a risk factor for complications such as preeclampsia, placental abruption, and fetal hypoxia. Iron-deficiency anemia is associated with an increased incidence of preterm birth, low-birth-weight infants, and maternal and infant mortality. Previous pregnancy complications are a risk factor for complications. Having a previous full-term pregnancy is not a risk factor for a current pregnancy.
Which position should the nurse recommend to relieve round ligament pain?
- A. Lying flat on the stomach
- B. Side-lying with a pillow between knees
- C. Sitting with legs crossed
- D. Standing for long periods
Correct Answer: B
Rationale: Side-lying with a pillow between knees supports the abdomen and reduces strain on round ligaments, relieving pain.
The nurse correctly assists the client into which position?
- A. Lithotomy
- B. Prone
- C. Sims'
- D. Trendelenburg's
Correct Answer: A
Rationale: The lithotomy position, with legs elevated and apart, is standard for pelvic examinations to provide access to the pelvic area.
The nurse is conducting a physical assessment of the pregnant client. Which physiological cervical changes associated with pregnancy should the nurse expect to find? Select all that apply.
- A. Formation of mucus plug
- B. Chadwick’s sign
- C. Presence of colostrum
- D. Goodell’s sign
- E. Cullen’s sign
Correct Answer: A,B,D
Rationale: Cervical changes associated with pregnancy include the formation of the mucus plug. Endocervical glands secrete a thick, tenacious mucus, which accumulates and thickens to form the mucus plug that seals the endocervical canal and prevents the ascent of bacteria or other substances into the uterus. This plug is expelled when cervical dilatation begins. Cervical changes associated with pregnancy include a bluish-purple discoloration of the cervix (Chadwick’s sign) from increased vascularization. Cervical changes associated with pregnancy include the softening of the cervix (Goodell’s sign) from increased vascularization and hypertrophy and engorgement of the vessels below the growing uterus. Colostrum does occur with pregnancy but is a physiological change associated with the breasts and not with a cervical change. Cullen’s sign is a bluish discoloration of the periumbilical skin caused by intraperitoneal hemorrhage. It can occur with a ruptured ectopic pregnancy or acute pancreatitis.
The nurse’s laboring client is being electronically monitored during her labor. The baseline FHR throughout the labor has been in the 130s. In the last 2 hours, the baseline has decreased to the 100s. How should the nurse document this FHR?
- A. Tachycardia
- B. Bradycardia
- C. Late deceleration
- D. Within normal limits
Correct Answer: B
Rationale: An FHR baseline less than 110 is classified as bradycardia. Tachycardia occurs when the baseline is greater than 160 bpm. A prolonged deceleration is defined as a change from the baseline FHR that occurs for 2 to 10 minutes before returning to baseline. A late deceleration is a gradual decrease and return of the FHR to baseline, associated with a uterine contraction. A decrease to the 100s is not within the normal range. The normal FHR is 120 to 160 bpm.