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The nurse is caring for a client at 34 weeks' gestation with suspected preterm labor. What is the priority nursing action?
- A. Administer corticosteroids as prescribed.
- B. Encourage ambulation to relieve contractions.
- C. Provide the client with a high-protein snack.
- D. Monitor maternal blood pressure.
Correct Answer: A
Rationale: The correct answer is A: Administer corticosteroids as prescribed. Administering corticosteroids helps accelerate fetal lung maturity and reduce the risk of respiratory distress syndrome in preterm infants. It is the priority action in suspected preterm labor at 34 weeks' gestation.
Explanation for why other choices are incorrect:
B: Encouraging ambulation may not be safe in preterm labor as it can increase the risk of delivering the baby prematurely.
C: Providing a high-protein snack is not the priority action in suspected preterm labor.
D: Monitoring maternal blood pressure is important, but not the priority in this situation where the focus is on preventing complications for the preterm infant.
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A nurse is educating a prenatal client on pregnancy 140 to 90 bpm that begins with the contraction changes and her gastrointestinal system. Which and gradually returns to the normal baseline statement is correct?
- A. Because of increased saliva production during related to? pregnancy, the client should use a medium to hard
- B. Uteroplacental insufficiency toothbrush to prevent plaque.
- C. Umbilical cord compression
- D. Heartburn may be relieved by sitting up after
Correct Answer: D
Rationale: The correct answer is D: Heartburn may be relieved by sitting up after. This is because during pregnancy, the growing uterus can push stomach acids upward, causing heartburn. Sitting up after eating can help prevent acid reflux by allowing gravity to keep stomach contents down.
Choice A is incorrect as increased saliva production during pregnancy is not related to toothbrush hardness. Choice B is incorrect because uteroplacental insufficiency is not related to the client's gastrointestinal system. Choice C is incorrect as umbilical cord compression is a separate issue and not related to heartburn relief.
The nurse is educating a pregnant client about foods high in iron. Which food should be recommended?
- A. Milk.
- B. Chicken.
- C. Spinach.
- D. Bananas.
Correct Answer: C
Rationale: The correct answer is C: Spinach.
1. Spinach is high in iron, which is important for pregnant women to prevent anemia.
2. Milk (A) does not contain a significant amount of iron.
3. Chicken (B) is a good source of protein but not as high in iron as spinach.
4. Bananas (D) are rich in potassium but not iron, making them a less suitable choice for iron supplementation during pregnancy.
The nurse is assessing a client in the active stage of labor. Which findings indicate to the nurse that the client is beginning the second stage of labor?
- A. The membranes have ruptured.
- B. The cervix is dilated completely.
- C. The client begins to expel clear vaginal fluid.
- D. The spontaneous urge to push is initiated from perineal pressure.
Correct Answer: B
Rationale: The correct answer is B because complete dilation of the cervix marks the transition from the first to the second stage of labor. This indicates that the client is ready to start pushing the baby out. Choice A is incorrect as ruptured membranes can occur in any stage of labor. Choice C is incorrect as clear vaginal fluid expulsion is not a specific indicator of the second stage. Choice D is incorrect as the urge to push can be experienced in the first stage as well.
The nurse is assessing a client with a suspected diagnosis of abruptio placentae. Which finding is most indicative of this condition?
- A. Soft abdomen.
- B. Uterine tenderness and rigidity.
- C. Bright red, painless vaginal bleeding.
- D. Decreased fetal movements.
Correct Answer: B
Rationale: The correct answer is B: Uterine tenderness and rigidity. This finding is most indicative of abruptio placentae, which is the premature separation of the placenta from the uterine wall. Uterine tenderness and rigidity are classic signs due to the internal bleeding and blood accumulating between the placenta and uterine wall. This results in a tense and tender uterus.
A: Soft abdomen is incorrect as abruptio placentae typically presents with a firm, board-like abdomen due to uterine rigidity.
C: Bright red, painless vaginal bleeding is incorrect as abruptio placentae typically presents with dark red, painful vaginal bleeding.
D: Decreased fetal movements are incorrect as fetal distress can occur with abruptio placentae, but uterine tenderness and rigidity are more specific indicators of this condition.
A nurse is assessing a client who is in active labor and notes that the presenting part is at 0 station. Which of the following is the correct interpretation of this clinical finding?
- A. The fetal head is in the left occiput posterior position.
- B. The largest fetal diameter has passed through the pelvic outlet.
- C. The posterior fontanel is palpable.
- D. The lowermost portion of the fetus is at the level of the ischial spines.
Correct Answer: D
Rationale: Correct Answer: D. The lowermost portion of the fetus is at the level of the ischial spines.
Rationale:
1. Station 0 indicates the presenting part of the fetus is at the level of the ischial spines.
2. This position is significant as it helps determine the progress of labor.
3. It means the fetus has not descended into the birth canal yet, indicating early labor stages.
Summary:
A: Incorrect. Left occiput posterior position is related to fetal head position, not station.
B: Incorrect. Passing through the pelvic outlet refers to engagement, not station.
C: Incorrect. The posterior fontanel being palpable is not directly related to station.