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The nurse is caring for a multigravid client at 34 weeks' gestation diagnosed with preterm labor. The client has delivered two stillborn infants at 30 weeks' gestation. The client is scheduled for a sonogram before an amniocentesis. Which of the following would be a priority nursing diagnosis for the client?
- A. Acute pain related to abnormal uterine contractions.
- B. Anxiety related to diagnostic tests for fetal well-being.
- C. Ineffective coping related to hospitalization.
- D. Deficient knowledge related to consequences of preterm birth.
Correct Answer: B
Rationale: Anxiety related to diagnostic tests is a priority.
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A primigravid client admitted to the labor area in the upper and lower lower than the lower was born with cystic fibrosis and she wonders if her baby will also have the disease. The nurse can tell the client that cystic fibrosis is:
- A. X-linked recessive and the disease will only occur if the baby is a boy.
- B. X-linked dominant and there is no likelihood of the baby having cystic fibrosis.
- C. Autosomal recessive and that unless the baby's father has the gene, the baby will not have the disease.
- D. Autosomal dominant and there is a 50 per cent chance of the baby having the disease.
Correct Answer: C
Rationale: Cystic fibrosis is an autosomal recessive disorder, requiring both parents to carry the gene for the child to be affected. If the father does not carry the gene, the baby cannot have the disease but may be a carrier. X-linked and dominant inheritance patterns do not apply.
A multigravid client at 40 weeks' gestation with a history of previous cesarean delivery is admitted for a trial of labor. The fetal monitor shows late decelerations. Which interventions should the nurse perform? Select all that apply.
- A. Administer oxygen at 8–10 L/min via mask.
- B. Stop the oxytocin infusion.
- C. Reposition the client to her right side.
- D. Increase the IV fluid rate.
- E. Apply a fetal scalp electrode.
Correct Answer: A,B,D
Rationale: Late decelerations suggest uteroplacental insufficiency. Administering oxygen, stopping oxytocin (if running), and increasing IV fluids improve fetal oxygenation and uterine perfusion. Right-side repositioning is less effective than left-side, and scalp electrodes are not the first step.
On the first postpartum day, the primiparous client reports perineal pain of 5 on a scale of 1 to 10 that was unrelieved by ibuprofen 800 mg given 2 hours ago. The nurse should further assess the client for:
- A. Puerperal infection.
- B. Vaginal lacerations.
- C. History of drug abuse.
- D. Perineal hematoma.
Correct Answer: D
Rationale: Persistent perineal pain unrelieved by ibuprofen suggests a perineal hematoma, which requires further assessment.
Two hours ago, a neonate at 38 weeks' gestation and weighing 3,175 g (7 lb) was born to a primiparous client who tested positive for beta-hemolytic Streptococcus. Which of the following would alert the nurse to notify the pediatrician?
- A. Alkalosis.
- B. Increased muscle tone.
- C. Temperature instability.
- D. Positive Babinski's reflex.
Correct Answer: C
Rationale: Temperature instability can indicate early sepsis, especially in a neonate at risk due to maternal beta-hemolytic Streptococcus.
Which of the following best identifies the reason for assessing a neonate weighing 1,500 g at 32 weeks' gestation for retinopathy of prematurity (ROP)?
- A. The neonate is at risk because of multiple factors.
- B. Oxygen is being administered at a level of $21%.
- C. The neonate was alkalotic immediately after birth.
- D. Phototherapy is likely to be ordered by the pediatrician.
Correct Answer: A
Rationale: Preterm neonates, especially those with low birth weight and receiving oxygen, are at risk for ROP due to immature retinal development.