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The nurse is caring for a client in the second stage of labor. What assessment indicates that birth is imminent?
- A. Cervix is dilated to 8 cm.
- B. Fetal head is crowning.
- C. Contractions every 3–5 minutes.
- D. Client reports back pain.
Correct Answer: B
Rationale: Crowning occurs when the fetal head becomes visible at the vaginal opening, indicating that birth is imminent.
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A pregnant client asks about the purpose of an ultrasound at 20 weeks' gestation. What is the best response?
- A. To confirm pregnancy viability.
- B. To check for genetic abnormalities.
- C. To assess fetal anatomy and growth.
- D. To determine the sex of the baby.
Correct Answer: C
Rationale: The 20-week ultrasound is primarily for assessing fetal anatomy, growth, and development.
A nurse on an antepartum unit is reviewing the medical records for four clients. Which of the following clients should the nurse assess first?
- A. A client who has diabetes mellitus and an HbA1c of 5.8%
- B. A client who has preeclampsia and a creatinine level of 1.1 mg/ dL
- C. A client who has hyperemesis gravidarum and a sodium level of 110 mEq/L
- D. A client who has placenta previa and a hematocrit of 36%
Correct Answer: C
Rationale: A client with hyperemesis gravidarum and a sodium level of 110 mEq/L is at risk for severe dehydration and electrolyte imbalance, particularly hyponatremia (low sodium level). Hyponatremia can lead to serious complications such as seizures, coma, and even death if not promptly addressed. Therefore, this client should be assessed first to prevent any potential life-threatening conditions. The nurse should prioritize interventions to address the electrolyte imbalance and dehydration in this client to ensure their safety and well-being.
The nurse is monitoring a pregnant client with severe preeclampsia. Which finding requires immediate intervention?
- A. Blood pressure of 140/90 mmHg.
- B. Urine output of 30 mL/hr.
- C. Complaints of headache and blurred vision.
- D. Weight gain of 1 pound in one week.
Correct Answer: C
Rationale: Headache and blurred vision are signs of worsening preeclampsia, indicating potential eclampsia.
A patient's newborn is neurologically impaired. The most important nursing action should be:
- A. Assist the patient and her family with the grieving process.
- B. Perform neurological assessments of the newborn every four hours.
- C. Arrange for social services to discuss possible placement of the newborn
- D. Obtain an order for an antidepressant to help the patient cope with the depressing news.
Correct Answer: A
Rationale: The most important nursing action when a patient's newborn is neurologically impaired is to assist the patient and her family with the grieving process. This situation can be extremely emotionally challenging for the parents and family as they come to terms with the newborn's condition. Providing support, empathy, and resources for coping with the grief is essential in helping the family navigate this difficult time. By being present, listening, and offering comfort, the nurse can help the family process their emotions and begin to cope with the situation. This support is crucial in promoting the overall well-being of the family as they adjust to the new reality of caring for a neurologically impaired newborn.
The nurse is caring for a client at 38 weeks' gestation with suspected placental abruption. What is the priority nursing action?
- A. Assess maternal vital signs and fetal heart rate.
- B. Prepare the client for immediate cesarean delivery.
- C. Administer oxygen at 2 L/min via nasal cannula.
- D. Insert an indwelling urinary catheter.
Correct Answer: A
Rationale: Assessing maternal and fetal status is the first step to determine the urgency and appropriate intervention.