Nokea
The nurse is caring for multiple clients. The nurse determines that which client would be a candidate for intermittent fetal monitoring during labor?
- A. The client with a previous cesarean birth
- B. The primigravida client at 41 weeks
- C. The client with preeclampsia
- D. The client with gestational diabetes
Correct Answer: B
Rationale: The client who is overdue by 7 days but has a reassuring FHR pattern is able to have intermittent fetal monitoring. Women with a previous cesarean birth are at an increased risk for uterine rupture. Women with preeclampsia are at an increased risk for placental insufficiency and need continuous monitoring during labor. Women with gestational diabetes are at an increased risk for placental insufficiency and need continuous monitoring during labor.
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The nurse recognizes which symptom as a warning sign of preterm labor?
- A. Mild lower back pain
- B. Regular contractions before 37 weeks
- C. Increased appetite
- D. Frequent urination
Correct Answer: B
Rationale: Regular contractions before 37 weeks are a key sign of preterm labor, requiring immediate medical attention.
The nurse advises a client with a history of miscarriage to monitor which symptom?
- A. Mild fatigue
- B. Vaginal spotting
- C. Increased appetite
- D. Normal fetal movement
Correct Answer: B
Rationale: Vaginal spotting may indicate a threatened miscarriage, requiring close monitoring and medical evaluation.
The laboring client tells the nurse that she wants to avoid an episiotomy if possible. Which response by the nurse is best?
- A. “Usually making an episiotomy incision is avoided whenever possible.”
- B. “Having an episiotomy reduces prolonged pushing and perineal trauma.”
- C. “An episiotomy is routine because it can prevent pelvic floor damage.”
- D. “Tell me more about your concerns about having an episiotomy.”
Correct Answer: A
Rationale: This statement is best. An episiotomy may be used in some circumstances but is usually avoided if possible. Use of episiotomy increases (not reduces) perineal trauma and increases healing time. Use of episiotomy is not routine, does not decrease pelvic floor damage, and may increase the severity of the trauma. Having the client tell the nurse more about her concerns regarding episiotomy is unnecessary and avoids responding to the client’s comment.
Which clients are most likely to be identified as being at high risk for pregnancy complications? Select all that apply.
- A. A client who is pregnant for the fifth time
- B. A client who is 16 years old
- C. A client who has a history of twins in the family
- D. A client who has primary hypertensive disease
- E. A client who works 40 hours a week in a factory
- F. A client who reports spotting in the first trimester
Correct Answer: A,B,D,F
Rationale: Multiple pregnancies, young age, hypertension, and spotting increase complication risks; twins or work hours are less significant.
The nurse assesses the client in her third trimester with suspected placenta previa. Which finding should the nurse associate with placenta previa?
- A. Cervix is 100% effaced
- B. Painless vaginal bleeding
- C. The fetal lie is transverse
- D. Absence of fetal movement
Correct Answer: B
Rationale: In placenta previa, the abnormal location of the placenta causes painless, bright red vaginal bleeding as the lower uterine segment stretches and thins. The nurse should not perform a vaginal examination to determine effacement on the client with suspected placenta previa. The lie of the fetus is not associated with placenta previa. An absence of fetal movement is always cause for concern but is not a primary symptom of placenta previa.