Nokea
The nurse is caring for the client in preterm labor who has gestational diabetes. The nurse determines that the client has a reactive NST when which findings are noted?
- A. Two fetal heart rate (FHR) accelerations of 15 beats per minute (bpm) above baseline for at least 15 seconds in a 20-minute period
- B. An FHR acceleration of 15 bpm above baseline for at least 10 seconds in the 40-minute time period for the NST
- C. Two FHR accelerations of 20 bpm above baseline when the mother changes position during the 20-minute NST
- D. The occurrence of at least three mild repetitive variable decelerations in the 20-minute time period for the NST
Correct Answer: A
Rationale: The FHR is monitored by the placement of an electronic fetal monitor that has an ultrasound transducer to record the FHR and a tocodynamometer to detect uterine or fetal movement. The client is given a handheld marker to indicate when she feels fetal movement. Fetal movement is accompanied by an increase in the FHR in the healthy fetus. The criterion for a reactive (normal) NST is the presence of two FHR accelerations of 15 bpm above baseline lasting 15 seconds or longer in a 20-minute period. One FHR acceleration during a 40-minute period is insufficient and indicates a nonreactive (abnormal) NST. Maternal movement can cause an inconsistency in the FHR on the monitor strip and should be avoided during an NST. The occurrence of at least three mild repetitive variable decelerations in a 20-minute period describes a nonreactive (abnormal) NST and fetal intolerance.
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The client at 32 weeks’ gestation presents to a hospital with a severe headache. Her admission BP is 184/104 mm Hg. Based on the assessment and findings of the serum laboratory report, which most severe complication warrants the nurse’s further assessment?
- A. Renal failure
- B. Liver failure
- C. Preeclampsia
- D. HELLP syndrome
Correct Answer: D
Rationale: It is most important for the nurse to further assess for HELLP syndrome, a variation of pregnancy-induced hypertension characterized by hemolysis (elevated bilirubin), elevated liver enzymes, and low platelets. The laboratory results do not show the serum creatinine level, so no inferences can be made about renal failure. Although liver enzymes are elevated, HELLP syndrome is a more severe complication associated with pregnancy. Preeclampsia commonly coexists with HELLP syndrome; however, these laboratory findings show worsening symptoms that are associated with HELLP syndrome.
Two hours after the client’s vaginal delivery, she reports feeling “several large, warm gushes of fluid” from her vagina. The nurse assesses the client’s perineum and finds a large pool of blood on the client’s bed. Which nursing action is priority?
- A. Encourage the client to ambulate to the bathroom in order to empty her bladder.
- B. Place two hands on the uterine fundus and prepare to vigorously massage the uterus.
- C. Reassure the client that heavy bleeding is expected in the first few hours postpartum.
- D. Support the lower uterine segment with one hand and assess the fundus with the other.
Correct Answer: D
Rationale: A full bladder may displace the uterus, causing increased bleeding. However, a more complete assessment must be performed prior to getting the client out of bed to prevent increased bleeding and syncope. Vigorously massaging the uterus may result in inversion of the uterus. The client should not simply be reassured that heavy bleeding is expected because further assessment is necessary before concluding that the client’s blood loss is WNL. The nurse’s first action should be to support the lower uterine segment and to assess the fundus. Increased bleeding will occur if soft or “boggy.” Failing to support the lower uterine segment may result in inversion of the uterus.
The nurse is caring for the 24-year-old client whose pregnancy history is as follows: elective termination age 18 years, spontaneous abortion age 21 years, term vaginal delivery at 22 years old, and currently pregnant again. Which documentation by the nurse of the client’s gravidity and parity is correct?
- A. G4P1
- B. G4P2
- C. G3P1
- D. G2P1
Correct Answer: A
Rationale: The client has been pregnant four times in all (gravidity). This client has delivered once (parity) and is currently pregnant, so the parity is 1. Although the client has been pregnant four times in all (gravidity), she would have had to deliver two fetuses over 20 weeks old, regardless of whether either fetus survived. The client has been pregnant four times in all, not three (gravidity). Parity of 1 is correct. The client has been pregnant four times in all, not two times (gravidity). Parity of 1 is correct.
The nurse is evaluating the 39-weeks-pregnant client who reports greenish, foul-smelling vaginal discharge. Her temperature is 101.6°F (38.7°C), and the FHR is 120 with minimal variability and no accelerations. The client’s group beta streptococcus (GBS) culture is positive. Which interventions should the nurse plan to implement? Select all that apply.
- A. Prepare for cesarean birth due to chorioamnionitis
- B. Start oxytocin for labor induction
- C. Start antibiotics as directed for the GBS infection
- D. Prepare the client for epidural anesthesia
- E. Notify the neonatologist of the client’s status
- F. Administer a cervical ripening agent
Correct Answer: A,C,D,E
Rationale: Because this client is not in labor and chorioamnionitis is possible, a cesarean birth is indicated. The client should be given antibiotics as prescribed to treat the infection. Because epidural anesthesia offers the least risk to the fetus, preparation for epidural anesthesia should begin. The pediatrician or neonatologist should be notified and available for the impending delivery. Starting oxytocin (Pitocin) would prolong the time to delivery. Administering a cervical ripening agent would prolong the time to delivery.
The nurse teaches the client to recognize which early labor sign?
- A. Bloody show
- B. Fatigue
- C. Increased appetite
- D. Mild nausea
Correct Answer: A
Rationale: Bloody show, a mucous discharge tinged with blood, is a common early labor sign as the cervix begins to dilate.