Nokea
The nurse is caring for a client in labor and delivery with the following history: G2 P1000, 39 weeks' gestation in transition phase, FH 135 with early decelerations. The client states, 'I'm so scared. Please make sure the baby is OK!' Which of the following responses by the nurse is appropriate?
- A. There is absolutely nothing to worry about.
- B. The fetal heart rate is within normal limits.
- C. How did your first baby die?
- D. Was your first baby preterm?
Correct Answer: B
Rationale: The fetal heart rate of 135 with early decelerations is within normal limits, which is reassuring. The nurse should provide factual information to alleviate the client's anxiety.
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Determine the obstetric history of a patient in her fifth pregnancy who has had two spontaneous abortions in the first trimester, one infant at 32 weeks' gestation, and one infant at 38 weeks' gestation.
- A. G5 T1 P2 A2 L 2
- B. G5 T1 P1 A1 L2
- C. G5 T0 P2 A2 L2
- D. G5 T1 P1 A2 L2
Correct Answer: D
Rationale: Rationale for Answer D (G5 T1 P1 A2 L2):
- G (Gravida): The patient is in her fifth pregnancy
- T (Term births): She has had one infant at 38 weeks' gestation
- P (Preterm births): She has had one infant at 32 weeks' gestation
- A (Abortions): She has had two spontaneous abortions in the first trimester
- L (Living children): She has 2 living children
Summary of other choices:
- A: Incorrect as it states 2 living children, which is not accurate
- B: Incorrect as it only accounts for one abortion and one living child
- C: Incorrect as it indicates no living children, which is not true based on the given information
Therefore, Answer D is the correct option based on the patient's obstetric history.
A client presents to Labor & Delivery for an ultrasound at 16 weeks gestation for vaginal bleeding. She asks the nurse if the procedure will harm her baby. Which is appropriate for the nurse to tell the client?
- A. Since you are already bleeding, we cannot guarantee that the ultrasound will not have any negative effects on your pregnancy.'
- B. Ultrasounds use sound waves to view your baby, not radiation, so the procedure will not harm your baby.'
- C. There are no guarantees when you have a procedure performed.'
- D. The doctor wouldn't try to order a test that would hurt your baby.'
Correct Answer: B
Rationale: The correct answer is B: "Ultrasounds use sound waves to view your baby, not radiation, so the procedure will not harm your baby."
Rationale:
1. Ultrasound uses sound waves, not radiation, to create images of the baby in the womb.
2. The sound waves are considered safe for both the mother and the developing baby.
3. There is no evidence to suggest that ultrasound procedures pose any harm to the pregnancy.
4. It is important to reassure the client that the ultrasound is a routine procedure and will not harm the baby.
Summary:
Choice A is incorrect because it wrongly implies that the ultrasound could potentially harm the baby due to the existing bleeding, which is not true.
Choice C is incorrect as it does not provide specific information regarding the safety of ultrasound during pregnancy.
Choice D is incorrect as it lacks the specific information about the safety of ultrasound and relies on a general statement about the doctor's intentions.
The nurse is reviewing the procedure for alpha-fetoprotein (AFP) screening with a patient at 16 weeks' gestation. The nurse determines that the patient understands the teaching when she states that will be collected for the initial screening process?
- A. Urine
- B. Blood
- C. Saliva
- D. Amniotic fluid
Correct Answer: B
Rationale: The correct answer is B: Blood. Alpha-fetoprotein (AFP) screening is a test that measures the level of AFP in the mother's blood to screen for certain fetal abnormalities. AFP is a protein produced by the fetus and can be detected in the mother's blood. Blood is the most appropriate sample for this screening as it directly reflects the fetal AFP levels. Urine (A), saliva (C), and amniotic fluid (D) do not contain AFP in levels that can be accurately measured for this screening, making them incorrect choices. Blood is the standard and most reliable sample for AFP screening due to its direct correlation with fetal AFP levels.
A pregnant woman is complaining of ptyalism. The nurse should teach the woman to try which of the following self-care measures?
- A. Use an astringent mouthwash.
- B. Elevate her legs frequently.
- C. Eat high-fiber foods.
- D. Void when the urge is felt.
Correct Answer: A
Rationale: Ptyalism, or excessive salivation, can be managed with astringent mouthwash to reduce saliva production.
The nurse is preparing to assist with the insertion of an intrauterine pressure catheter and a fetal spiral electrode. What is required for proper placement by the practitioner? Select all that apply.
- A. Rupture of membranes
- B. Dilated cervix
- C. Vertex fetus
- D. Moderate variability
Correct Answer: A
Rationale: Correct Answer: A - Rupture of membranes
Rationale:
1. Rupture of membranes is necessary for the insertion of intrauterine pressure catheter and fetal spiral electrode.
2. It allows safe passage of the catheter and electrode into the uterus.
3. Without ruptured membranes, there is a risk of infection and difficulty in inserting the devices.
Summary:
- Choice B (Dilated cervix) is not required for the insertion of these devices.
- Choice C (Vertex fetus) is not a factor in the insertion process.
- Choice D (Moderate variability) is related to fetal heart rate monitoring, not device insertion.