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The nurse is teaching a client about foods rich in folic acid during pregnancy. Which food should the nurse recommend?
- A. Citrus fruits.
- B. Lean meats.
- C. Dairy products.
- D. Whole grains.
Correct Answer: A
Rationale: The correct answer is A, citrus fruits. Folic acid is important for fetal development and helps prevent birth defects. Citrus fruits like oranges, grapefruits, and lemons are rich sources of folic acid. They provide the necessary nutrients for a healthy pregnancy. Lean meats (B) are good sources of protein but not specifically high in folic acid. Dairy products (C) are important for calcium but do not contain significant amounts of folic acid. Whole grains (D) are beneficial for fiber and nutrients, but they are not the best source of folic acid compared to citrus fruits.
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The nurse is monitoring a client during the first stage of labor. What finding requires immediate intervention?
- A. Contractions every 3–5 minutes.
- B. Baseline fetal heart rate of 110 beats/minute.
- C. Variable decelerations on the fetal monitor.
- D. Client reports back pain during contractions.
Correct Answer: C
Rationale: The correct answer is C because variable decelerations on the fetal monitor indicate umbilical cord compression, which can lead to fetal distress and hypoxia. Immediate intervention is needed to relieve the compression and prevent potential harm to the baby. Contractions every 3-5 minutes (A) are normal in the first stage of labor. A baseline fetal heart rate of 110 beats/minute (B) is within the normal range for a fetus. Client reporting back pain (D) is a common symptom of labor and not necessarily indicative of a complication requiring immediate intervention.
What is the most critical sign of fetal distress during labor?
- A. Accelerations in fetal heart rate
- B. Decreased variability in fetal heart rate
- C. Early decelerations in fetal heart rate
- D. Late decelerations in fetal heart rate
Correct Answer: D
Rationale: The correct answer is D: Late decelerations in fetal heart rate. Late decelerations indicate uteroplacental insufficiency, where the fetus is not receiving enough oxygen during contractions. This is critical as it can lead to fetal hypoxia and acidosis, posing a risk to the baby's well-being. Early decelerations (C) are generally benign and result from head compression during contractions. Accelerations (A) are a reassuring sign indicating fetal well-being. Decreased variability (B) can be concerning but is not as critical as late decelerations in indicating fetal distress.
A nurse is providing teaching about terbutaline to a client who is experiencing preterm labor. Which of the following statement by client indicates an understanding of the teaching?
- A. "The medication could cause me to experience heart palpitation"
- B. "This medication could cause me to experience blurred vision"
- C. "This medication could cause me to experience ringing in my ears"
- D. "This medication could cause me to experience frequent "¦"
Correct Answer: A
Rationale: The correct answer is A. The statement "The medication could cause me to experience heart palpitations" indicates understanding because terbutaline, a beta-agonist used to stop preterm labor, can indeed cause heart palpitations as a common side effect due to its impact on the cardiovascular system. This shows the client has grasped a potential side effect of the medication.
The other choices are incorrect:
B: "This medication could cause me to experience blurred vision" - Blurred vision is not a common side effect of terbutaline.
C: "This medication could cause me to experience ringing in my ears" - Ringing in the ears is not a common side effect of terbutaline.
D: "This medication could cause me to experience frequent " - Incomplete statement, not indicating understanding of a specific side effect.
A nurse on a labor and delivery unit is receiving infection control standards with a newly licensed nurse. The nurse should instruct the newly licensed nurse to don gloves for which of the following procedures?
- A. Assisting a mother with breastfeeding
- B. Performing a newborn's initial bath
- C. Administering the measles, mumps, rubella vaccine
- D. Performing umbilical cord care
Correct Answer: D
Rationale: The correct answer is D: Performing umbilical cord care. Gloves should be worn during this procedure to prevent the spread of infection. The umbilical cord stump is a potential entry point for bacteria, so gloves are necessary to maintain asepsis.
A: Assisting a mother with breastfeeding does not require gloves as it is a clean procedure.
B: Performing a newborn's initial bath does not require gloves unless there are open wounds on the newborn.
C: Administering the measles, mumps, rubella vaccine may require gloves, but the primary concern is needlestick safety rather than infection control through glove use.
A client in labor with ruptured membranes is diagnosed with chorioamnionitis. What is the priority nursing action?
- A. Administer prescribed antibiotics.
- B. Encourage the client to ambulate.
- C. Increase the oxytocin infusion rate.
- D. Perform a sterile vaginal examination.
Correct Answer: A
Rationale: The correct answer is A: Administer prescribed antibiotics. The priority nursing action in a client with chorioamnionitis is to administer antibiotics promptly to prevent infection spread to the fetus and mother. Antibiotics help treat the infection and reduce complications. Encouraging ambulation (B) may not be safe due to the risk of infection. Increasing oxytocin infusion rate (C) could worsen the infection. Performing a sterile vaginal examination (D) is contraindicated as it can introduce more bacteria. Administering antibiotics is the most urgent and effective intervention in this situation.