Nokea
The nurse is monitoring a client receiving oxytocin for labor induction. What finding requires the nurse to take immediate action?
- A. Contractions lasting 90 seconds.
- B. Contractions every 2–3 minutes.
- C. Fetal heart rate of 180 beats/minute.
- D. Client reports mild nausea.
Correct Answer: C
Rationale: A fetal heart rate of 180 bpm indicates tachycardia, which may suggest fetal distress requiring immediate intervention.
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The nurse is assessing a client with suspected gestational hypertension. What finding supports this diagnosis?
- A. Blood pressure of 150/90 mmHg.
- B. Proteinuria of +2.
- C. Fetal heart rate of 140 beats/minute.
- D. Mild edema in the lower extremities.
Correct Answer: A
Rationale: Gestational hypertension is diagnosed with a blood pressure of 140/90 mmHg or higher without proteinuria.
A patient who uses a diaphragm as contraception asks if they need to use a backup method. What should the nurse respond?
- A. No, the diaphragm is effective on its own and does not require a backup method.
- B. Yes, a diaphragm is effective only when used with spermicide, so a backup method is advised.
- C. Yes, a diaphragm should always be used with a condom for additional protection.
- D. No, but the diaphragm should be replaced every 6 months.
Correct Answer: B
Rationale: The diaphragm should be used with spermicide for maximum effectiveness. Choice A is incorrect because while the diaphragm is effective, spermicide enhances its performance and ensures greater protection. Choice C is unnecessary, as the diaphragm alone with spermicide is sufficient. Choice D is incorrect because while regular replacement is recommended, it does not require a backup method.
A laboring patient's obstetrician suggested an amniotomy as a method for inducing the labor. Which assessment must be made before the amniotomy is performed?
- A. Fetal presentation, position, and station
- B. Estimate fetal birth weight
- C. Maternal temperature, BP, pulse
- D. Biparietal diameter
Correct Answer: A
Rationale: Before performing an amniotomy (artificial rupture of membranes), it is essential to assess the fetal presentation, position, and station. This assessment helps ensure that the procedure is performed safely without causing harm to the baby. Knowing the fetal presentation (such as breech, transverse, or vertex), position (occiput anterior, occiput posterior, etc.), and station (how far down the baby's head is in the pelvis) allows the obstetrician to determine the best approach and technique for the amniotomy. It also helps in reducing the risk of complications during labor induction and delivery. Therefore, this assessment is crucial in ensuring the well-being of both the mother and the baby during the labor process.
A nurse is admitting a client who has a diagnosis of preterm labor. The nurse anticipates a prescription by the provider for which of the following medications? (Select all that apply.)
- A. Prostaglandin E2
- B. Indomethacin
- C. Magnesium sulfate
- D. Methylergonovine
Correct Answer: A
Rationale: A. Prostaglandin E2: Prostaglandin E2 is used to manage preterm labor by helping to ripen the cervix and promote contractions.
As a nurse working in a prenatal clinic. It is important to obtain maternal and fetal assessing. While obtaining fetal assessments. Which of the following should the complete for fetal well-being?
- A. Fetal movement, maternal vital signs, maternal weight
- B. Fetal movement, fetal position, fetal weight
- C. Fetal position, fetal heart tone, maternal weight
- D. Fetal heart tones, fetal movement, fundal height
Correct Answer: D
Rationale: When assessing fetal well-being in a prenatal clinic, it is important to focus on factors directly related to the fetus. Fetal heart tones provide crucial information about the baby's heart rate and rhythm, indicating how well the fetus is doing. Fetal movement is another essential indicator of fetal well-being, as it shows signs of good neurological function and reactivity. Finally, measuring fundal height (the distance from the top of the uterus to the pubic bone) helps assess fetal growth and development. These three aspects - fetal heart tones, fetal movement, and fundal height - provide a comprehensive evaluation of the baby's well-being and development during pregnancy.