Nokea
The nurse is caring for a postpartum client who is
- A. Maternal hyperglycemia 1 day postcesarean birth. What assessment data
- B. FHR, early decelerations would indicate infection? Select all that apply.
- C. FHR, late decelerations
- D. Increased pulse
Correct Answer: A
Rationale: Maternal hyperglycemia 1 day post-cesarean birth can indicate infection. Hyperglycemia can impair immune function and make the body more susceptible to infections.
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The laboring person asks the nurse to review the birth plan. What item is on a typical birth plan?
- A. where the patient will be staying after birth
- B. who will be watching their other children
- C. what position they want to birth in
- D. how they will time contractions
Correct Answer: C
Rationale: Birth plans often include preferences for birthing positions to promote comfort and effectiveness.
The nurse is preparing a client for a nonstress test. What instruction is most appropriate?
- A. You need to fast for 12 hours before the test.
- B. You will be given medication to stimulate fetal movements.
- C. You will need to press a button each time you feel the baby move.
- D. You must lie flat on your back during the test.
Correct Answer: C
Rationale: The client presses a button during fetal movements, which are correlated with fetal heart rate changes.
A client at 34 weeks' gestation is diagnosed with polyhydramnios. What is the nurse's priority assessment?
- A. Monitor maternal blood pressure.
- B. Assess for signs of preterm labor.
- C. Check for signs of infection.
- D. Evaluate for fetal heart rate changes.
Correct Answer: B
Rationale: Polyhydramnios increases the risk of preterm labor due to uterine overdistension, requiring close monitoring.
A woman has been having contractions since 4am this morning. At 8am her cervix dilated 5cm. Contractions are frequent, mild to moderate in intensity. CPD has been ruled out. After giving her sedation so she can rest, what would anticipate preparing her for?
- A. oxytocin induction
- B. Amnioinfusion
- C. c/s
- D. increased IV infusion
Correct Answer: C
Rationale: The scenario describes a woman in active labor with frequent, mild to moderate contractions and significant cervical dilation. If cephalopelvic disproportion (CPD) has been ruled out and the progress of labor is slow despite sufficient dilation and descent of the fetus, it may indicate cephalopelvic disproportion, failure to progress, or other complications that could necessitate a cesarean section (c/s). In this case, providing sedation to allow for rest suggests that the medical team is considering the possibility of further intervention, such as a c/s, if the labor does not progress effectively despite sufficient dilation. Therefore, preparing the woman for a c/s would be the anticipated next step in her care.
A nurse is assessing a preterm newborn who is at 32 weeks of gestation. Which of the following finding should the nurse expect?
- A. Minimal arm recoil
- B. Popliteal angle of less than 90
- C. Creases over the entire sole
- D. Sparse lanugo
Correct Answer: B
Rationale: A preterm newborn at 32 weeks of gestation is usually characterized by hip flexion posturing and a popliteal angle of less than 90 degrees. The popliteal angle is the angle at the back of the knee joint when the leg is flexed, and a value of less than 90 degrees is commonly seen in preterm newborns due to their muscle tone immaturity. This finding is consistent with the developmental stage of a preterm infant at 32 weeks gestation.