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The nurse is performing an assessment of a client who is scheduled for a cesarean delivery at 39 weeks of gestation. Which assessment finding indicates the need to contact the health care provider (HCP)?
- A. Hemoglobin of 11 g/dL (110 mmol/L)
- B. Fetal heart rate of 180 beats/minute
- C. Maternal pulse rate of 85 beats/minute
- D. White blood cell count of 12,000 mm3 (12.0 × 109/L)
Correct Answer: B
Rationale: A fetal heart rate of 180 bpm may indicate fetal distress and warrants immediate HCP notification.
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A nurse is caring for a client who is in premature labor and is receiving terbutaline. The nurse should monitor the client for which of the following adverse effects that should be reported to the provider?
- A. Headaches B Nervousness
- B. Tremors
- C. Dyspnea
Correct Answer: C
Rationale: Terbutaline is a beta-adrenergic agonist that is commonly used to suppress preterm labor by relaxing the uterine smooth muscle. Adverse effects of terbutaline can include respiratory distress or dyspnea, which is a serious concern and should be reported to the healthcare provider immediately. Both the nurse and the client should be alert for signs of difficulty breathing, such as shortness of breath or chest tightness, as these symptoms could indicate a potential serious reaction to the medication. Headaches, nervousness, and tremors are common side effects of terbutaline that are less concerning and may not require immediate provider notification unless they become severe or persistent.
How should a nurse respond to a mother asking about newborn hearing screening?
- A. Explain that hearing screening is optional
- B. Reassure the mother that this is a routine test
- C. Inform the mother that hearing screening is mandatory
- D. Provide resources for further testing if needed
Correct Answer: B
Rationale: Hearing screening is a routine test to identify hearing issues early and ensure proper interventions.
A nurse is providing teaching about expected changes during pregnancy to a client who is at 24 weeks of gestation. Which of the following information should the nurse include?
- A. "Your stomach will empty rapidly"
- B. "You should expect your uterus to double in size"
- C. "You should anticipate nasal stuffiness."
- D. "Your nipples will become lighter in color".
Correct Answer: B
Rationale: Option B, "You should expect your uterus to double in size," is the correct information to include when discussing expected changes during pregnancy at 24 weeks of gestation. By this time, the uterus has significantly expanded to accommodate the growing fetus, which is the most notable physical change during pregnancy. It is essential for the client to understand the normal physiological changes that occur during pregnancy to ensure they are informed and prepared for the expected progression of their pregnancy.
The nurse is educating a client about signs of preterm labor. What symptom should be reported immediately?
- A. Frequent urination.
- B. Low back pain and cramping.
- C. Increased appetite.
- D. Braxton Hicks contractions.
Correct Answer: B
Rationale: Low back pain and cramping can indicate preterm labor and should be reported immediately for further evaluation.
Which of the following medications should the nurse plan to administer?
- A. Metronidazole
- B. Penicillin
- C. Acyclovir
- D. Gentamicin
Correct Answer: A
Rationale: Among the medications listed, Metronidazole is commonly used to treat anaerobic bacterial infections, protozoal infections, and certain types of parasitic infections. It is effective against a wide range of pathogens, making it a versatile antibiotic. In this case, the nurse should plan to administer Metronidazole based on the information given in the question. Penicillin is primarily used for Gram-positive bacterial infections, Acyclovir is used for herpes virus infections, and Gentamicin is an aminoglycoside antibiotic typically used for Gram-negative bacterial infections.