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The nurse is monitoring a client during the first stage of labor. What finding requires immediate intervention?
- A. Contractions every 3–5 minutes.
- B. Baseline fetal heart rate of 110 beats/minute.
- C. Variable decelerations on the fetal monitor.
- D. Client reports back pain during contractions.
Correct Answer: C
Rationale: The correct answer is C because variable decelerations on the fetal monitor indicate umbilical cord compression, which can lead to fetal distress and hypoxia. Immediate intervention is needed to relieve the compression and prevent potential harm to the baby. Contractions every 3-5 minutes (A) are normal in the first stage of labor. A baseline fetal heart rate of 110 beats/minute (B) is within the normal range for a fetus. Client reporting back pain (D) is a common symptom of labor and not necessarily indicative of a complication requiring immediate intervention.
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The nurse is teaching a client about foods rich in folic acid during pregnancy. Which food should the nurse recommend?
- A. Citrus fruits.
- B. Lean meats.
- C. Dairy products.
- D. Whole grains.
Correct Answer: A
Rationale: The correct answer is A, citrus fruits. Folic acid is important for fetal development and helps prevent birth defects. Citrus fruits like oranges, grapefruits, and lemons are rich sources of folic acid. They provide the necessary nutrients for a healthy pregnancy. Lean meats (B) are good sources of protein but not specifically high in folic acid. Dairy products (C) are important for calcium but do not contain significant amounts of folic acid. Whole grains (D) are beneficial for fiber and nutrients, but they are not the best source of folic acid compared to citrus fruits.
The nurse is reviewing lab results for a pregnant client. Which finding is most concerning?
- A. Hemoglobin of 11 g/dL.
- B. WBC count of 14,000 mm3.
- C. Platelet count of 90,000 mm3.
- D. Fasting blood glucose of 90 mg/dL.
Correct Answer: C
Rationale: The correct answer is C: Platelet count of 90,000 mm3. A low platelet count (thrombocytopenia) in pregnancy can lead to serious complications like bleeding disorders or preeclampsia. Hemoglobin level of 11 g/dL is within normal range for pregnancy. WBC count of 14,000 mm3 may indicate infection but is not as concerning as thrombocytopenia. Fasting blood glucose of 90 mg/dL is also normal in pregnancy.
A patient 11 weeks' gestation comes to the emergency room department with c/o dizziness, abdominal pain, and shoulder pain. Lab tests reveal a beta-hcg lower than expected level for gestational age
- A. Ultrasound confirms no intrauterine
- B. The nurse knows the most likely diagnostic is an ectopic pregnancy. What statement should the nurse use to explain to the patient?
- C. The baby is in the fallopian tube, the tube has ruptured and is causing bleeding
Correct Answer: B
Rationale: Step 1: Recognize Symptoms - Dizziness, abdominal pain, shoulder pain, low beta-hcg.
Step 2: Consider Ectopic Pregnancy - Symptoms align with ectopic pregnancy.
Step 3: Rule Out Miscarriage - Low beta-hcg indicates not viable intrauterine pregnancy (Choice A).
Step 4: Understand Ectopic Pregnancy - Explaining ectopic pregnancy (Choice C) and rupture to patient may cause distress.
Step 5: Communicate - Nurse should use simple, empathetic statement (Choice B) to explain the likely diagnosis.
Summary: Choice B is correct as it addresses the likely diagnosis without causing undue distress to the patient, unlike Choices A and C which may lead to confusion and anxiety.
A client at 28 weeks' gestation with gestational diabetes is undergoing a nonstress test. What is a reassuring result?
- A. Two accelerations in 20 minutes.
- B. Fetal heart rate of 170 beats/minute.
- C. Decreased fetal movement.
- D. Variable decelerations.
Correct Answer: A
Rationale: The correct answer is A: Two accelerations in 20 minutes. Accelerations in fetal heart rate during a nonstress test indicate fetal well-being and adequate oxygenation. Two accelerations in 20 minutes are reassuring as they show a normal response to fetal movement and suggest a healthy fetal nervous system.
Option B is incorrect because a fetal heart rate of 170 beats/minute may indicate fetal distress or tachycardia. Option C is incorrect as decreased fetal movement can be a sign of fetal compromise. Option D is incorrect as variable decelerations can indicate umbilical cord compression and require further evaluation.
A nurse in the emergency department is admitting a client who is at 40 weeks of gestation, has ruptured membranes, and the nurse observes the newborn's head is crowning. The client tells the nurse she wants to push. Which of the following statements should the nurse make? to
- A. "You should go ahead and push to assist the delivery."
- B. "You should try to pant as the delivery proceeds."
- C. "You should try to perform slow-paced breathing."
- D. "You should take a deep, cleansing breath and breathe naturally."
Correct Answer: A
Rationale: The correct answer is A because the newborn's head crowning indicates imminent delivery, and the client's urge to push aligns with the natural progression of labor. By encouraging the client to push, the nurse facilitates the safe and timely delivery of the baby. Panting (choice B) or slow-paced breathing (choice C) may not be effective in this advanced stage of labor. Taking a deep cleansing breath (choice D) can delay the delivery and is not recommended when the baby is crowning.