Nokea
The nurse is monitoring a client in labor with an epidural. What finding requires immediate intervention?
- A. Blood pressure of 100/60 mmHg.
- B. Fetal heart rate of 90 beats/minute.
- C. Client reports warmth in the lower extremities.
- D. Contractions every 5 minutes.
Correct Answer: B
Rationale: The correct answer is B: Fetal heart rate of 90 beats/minute. A fetal heart rate of 90 bpm indicates fetal distress and requires immediate intervention to prevent potential complications. Decreased fetal heart rate can be a sign of fetal hypoxia or distress. The other choices are not as concerning in this context. A blood pressure of 100/60 mmHg is within normal range. The client reporting warmth in the lower extremities is a common side effect of epidural anesthesia. Contractions every 5 minutes may indicate progress in labor but do not require immediate intervention unless associated with fetal distress.
You may also like to solve these questions
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 nurse is preparing to administer magnesium sulfate IV to a client who is experiencing preterm labor. Which of the following is the priority nursing assessment for this client?
- A. Temperature
- B. Fetal heart rate (FHR)
- C. Bowel sounds
- D. Respiratory rate
Correct Answer: B
Rationale: The correct answer is B: Fetal heart rate (FHR). When administering magnesium sulfate for preterm labor, monitoring the fetal heart rate is crucial as magnesium sulfate can affect the fetal heart rate. It is important to assess for any signs of fetal distress promptly.
A: Temperature is important to monitor for signs of magnesium toxicity, but not the priority assessment in this situation.
C: Bowel sounds are not directly related to the administration of magnesium sulfate for preterm labor.
D: Respiratory rate is important to monitor for respiratory depression from magnesium sulfate, but assessing the fetal heart rate takes precedence in this scenario.
The nurse would classify a newborn delivered at 39 weeks' gestation, weighing 2400 g ( 5.0 lbs) as being:
- A. Preterm and immature
- B. Small-for-gestational age
- C. Average-for-gestational age
- D. Average-for-gestational age but pre-term
Correct Answer: B
Rationale: The correct answer is B: Small-for-gestational age. A newborn delivered at 39 weeks' gestation and weighing 2400g is considered small-for-gestational age because the weight is below the 10th percentile for the gestational age. This indicates intrauterine growth restriction. Preterm and immature (choice A) would not apply as the baby was delivered at term. Average-for-gestational age (choice C) would not be accurate as the baby's weight is below the normal range for that gestational age. Choice D is also incorrect as the baby is not within the average weight range for the gestational age.
A nurse is developing an educational program about hemolytic diseases in newborns for a group of newly licensed nurses. Which of the following genetic information should the nurse include in the program as a cause of hemolytic disease?
- A. The mother is Rh positive, and the father is Rh negative
- B. The mother is Rh negative, and the father is Rh positive
- C. The mother and the father are both Rh positive
- D. The mother and the father are both Rh negative
Correct Answer: B
Rationale: The correct answer is B: The mother is Rh negative, and the father is Rh positive. This combination can lead to hemolytic disease in newborns due to Rh incompatibility. If the mother is Rh negative and the father is Rh positive, there is a chance that the fetus may inherit the Rh-positive factor from the father, causing the mother's immune system to produce antibodies against the Rh factor in subsequent pregnancies, potentially leading to hemolytic disease in newborns.
Incorrect choices:
A: The mother is Rh positive, and the father is Rh negative - This combination does not result in Rh incompatibility as the fetus will not inherit the Rh-negative factor from the father.
C: The mother and the father are both Rh positive - Rh incompatibility occurs when the mother is Rh negative and the father is Rh positive, so this choice is incorrect.
D: The mother and the father are both Rh negative - In this case, there is no Rh incompatibility present,
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.