Nokea
The nurse is caring for a client who had a contraction stress test. Which change in assessment requires immediate notification of the health care provider?
- A. No late decelerations
- B. Late decelerations with at least 50% of the contractions
- C. Accelerations with contractions
- D. No contractions produced
Correct Answer: B
Rationale: The correct answer is B because late decelerations with at least 50% of contractions indicate fetal distress and potential hypoxia. This requires immediate notification of the healthcare provider for further evaluation and intervention. No late decelerations (choice A) are normal. Accelerations with contractions (choice C) are reassuring. No contractions produced (choice D) would indicate an inadequate test and require reevaluation.
You may also like to solve these questions
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 nurse has provided a young woman with preconception counseling. Which of the statements by the woman indicates that the teaching was successful? Select all that apply.
- A. “As soon as I think I may be pregnant, I should stop drinking alcohol.”
- B. “It is important for me to see my medical doctor for a complete physical.”
- C. “I should make sure that my daily multivitamin contains folic acid.”
- D. “When I go to my dentist for a checkup I should state that I may be pregnant.”
Correct Answer: A
Rationale: All the statements indicate successful preconception counseling, covering topics such as alcohol cessation, medical checkups, folic acid intake, dental care, and dietary precautions.
The nurse is discussing the purpose of the physical examination with a patient at the first prenatal visit. What information does the nurse include in the discussion?
- A. The physical exam helps to confirm the patient's current health.
- B. The physical exam determines nutritional risk factors.
- C. The physical exam confirms the diagnosis of STIs.
- D. The physical exam includes urinalysis.
Correct Answer: A
Rationale: The correct answer is A because the physical exam at the first prenatal visit aims to confirm the patient's current health status, assess baseline health indicators, and identify any potential risks or issues that may affect the pregnancy. This information is crucial for developing a personalized care plan for the patient and ensuring a healthy pregnancy outcome.
Choice B is incorrect because determining nutritional risk factors typically involves assessing dietary habits, weight, and specific nutrient deficiencies, which are not solely addressed through a physical exam.
Choice C is incorrect as confirming the diagnosis of STIs would require specific testing and not solely rely on a physical examination.
Choice D is incorrect because while urinalysis may be part of the physical exam, its primary purpose is not solely to include urinalysis but to comprehensively evaluate the patient's overall health.
When should the nurse begin discharge planning?
- A. When the patient is ready
- B. Close to the time of discharge
- C. Upon admission to the hospital
- D. After an order is written/prescribed
Correct Answer: C
Rationale: Discharge planning begins the moment a patient is admitted to a health care facility.
An NST is performed on a client who is G6T3P1A1L4 38 weeks gestation. After the patient has been on the external monitor for 30 minutes, the nurse sees three fetal heart rate accelerations of 15 bpm lasting 5 seconds in association with fetal movement. The nurse documents this finding as which of the following?
- A. Unsatisfactory
- B. A reactive NST
- C. A nonreactive nonstress test
- D. Equivocal suspicious
Correct Answer: B
Rationale: The correct answer is B: A reactive NST. This is because the NST shows three fetal heart rate accelerations of 15 bpm lasting 5 seconds each, in association with fetal movement. A reactive NST indicates a normal response, which is characterized by the presence of fetal heart rate accelerations associated with fetal movement. This is a reassuring finding, suggesting fetal well-being.
Choice A (Unsatisfactory) is incorrect because the description of the findings indicates a satisfactory response. Choice C (A nonreactive nonstress test) is incorrect because the test showed accelerations in response to fetal movements, which is not consistent with a nonreactive test. Choice D (Equivocal suspicious) is incorrect as there is no indication of uncertainty or suspicion in the findings described.