Nokea
The nurse is reviewing laboratory results of the client in labor prior to her receiving epidural anesthesia. Which result is most important to report to the HCP prior to the initiation of the epidural?
- A. White blood cells: 24,000/mm3
- B. Glucose: 78 grams/dL
- C. Hemoglobin: 10.2 g/dL
- D. Platelets: 100,000/mm3
Correct Answer: D
Rationale: The nurse should report the low platelet count of 100,000/mm3 (normal is 150,000 to 450,000/mm3). A low count can contribute to bleeding and affect the use of epidural anesthesia. The WBC count in labor is normally increased due to the stress of labor and can be as high as 25,000/mm3 to 30,000/mm3. The glucose level normally falls during labor because of an expenditure of energy in labor. Anemia or a reduction in the Hgb and Hct is common in pregnancy. Hgb levels less than 10 g/dL are considered abnormal in pregnancy.
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The nurse observes on the monitor tracing of the client in the transition phase of labor that the baseline FHR is 160 and that there is moderate variability with V-shaped decelerations unrelated to contractions. What should the nurse do first?
- A. Prepare for delivery.
- B. Notify the obstetrician.
- C. Apply oxygen nasally.
- D. Reposition the client.
Correct Answer: D
Rationale: Repositioning the client to her side or to knee-chest should be done first to take the pressure off the umbilical cord. Variable decelerations usually result from cord compression and stretching during fetal descent. The fetus has a normal baseline HR and good variability. There is no indication that immediate delivery is necessary. Other measures could correct the V-shaped (variable) decelerations. Other nursing measures are used to correct the V-shaped (variable) decelerations prior to contacting the obstetrician (or midwife). Repositioning the client should be implemented prior to giving her oxygen.
A 5-minute-old newborn in a delivery room has a good cry, HR 88, well flexed, good reflex irritability, and blue extremities with a completely pink body. What Apgar score would the nurse document for this newborn?
Correct Answer: 8
Rationale: The newborn would receive one point because the HR is below 100 bpm, two points for a good cry (respiratory effort), two points for being well flexed (muscle tone), two points for good reflex irritability (reflex response), and one point for a pink body with blue extremities (color).
Which newborn behavior is normal and does not require immediate concern?
- A. Frequent hiccups
- B. Persistent vomiting
- C. Lethargy for days
- D. High fever
Correct Answer: A
Rationale: Frequent hiccups are normal in newborns and typically resolve without intervention, unlike the other symptoms.
Using Naegele's Rule, the nurse can assume the client's expected delivery date to be approximately which date?
- A. 13-Nov
- B. 23-Nov
- C. 3-Dec
- D. 20-Dec
Correct Answer: C
Rationale: Naegele's Rule: Subtract 3 months from the first day of the last menstrual period (March 13) and add 7 days, resulting in December 3.
The nurse is caring for the client in labor. Which assessment finding would help the nurse determine whether the client is in the third stage of labor?
- A. Lengthening of fetal cord
- B. Increased bloody show
- C. A strong urge to push
- D. More frequent contractions
Correct Answer: A
Rationale: The third stage of labor lasts from the birth of the baby until the placenta is expelled. Lengthening of the fetal cord is one of several signs indicating placental separation. Bloody show is pink and mucoid in nature and occurs during the first and second stages of labor. During the third stage, there may be increased vaginal bleeding that is bright or dark red. A strong urge to push may occur during the first and second stages of labor. More frequent contractions occur during the first and second stages of labor.