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The nurse observes a fetal heart rate pattern on the monitor: baseline 160 beats per minute with minimal variability, a decrease to 150 beats per minute beginning after the contraction starts and returns to baseline after the contraction ends. Which finding should the nurse document in the electronic medical record?
- A. Variable decelerations.
- B. Late decelerations.
- C. No decelerations.
- D. Early decelerations.
Correct Answer: B
Rationale: The described pattern matches late decelerations, indicating potential utero-placental insufficiency, as the fetal heart rate decreases after the contraction starts and recovers post-contraction.
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A nurse is conducting a preconception class for a group of parents who are anticipating having children. Which client(s) should the nurse refer for genetic counseling? (Select all that apply)
- A. A couple who express concern about birth defects after using an internet DNA testing site.
- B. A woman and her significant other who are excited about the prospect of having children.
- C. A woman planning to start a second family after the loss of an embryo following an in-vitro fertilization procedure.
- D. A man who states that his father was recently diagnosed with Huntington's disease.
- E. A couple who plan to use in-vitro fertilization with donated sperm.
Correct Answer: A,C,D,E
Rationale: Concerns about birth defects, embryo loss, Huntington's disease, and donor sperm use indicate potential genetic risks requiring counseling, unlike general excitement about having children.
A client whose labor is being augmented with an oxytocin infusion requests an epidural for pain control. Findings of the last vaginal exam, performed 1 hour ago, were 3 cm cervical dilation, 60% effacement, and a -2 station. Which action should the nurse implement first?
- A. Request placement of the epidural.
- B. Give a bolus of intravenous fluids.
- C. Decrease the oxytocin infusion rate.
- D. Determine current cervical dilation.
Correct Answer: D
Rationale: Assessing current cervical dilation ensures labor progress is suitable for epidural placement, preventing complications like slowed labor.
Which action should the nurse take?
- A. Document the normal finding.
- B. Notify the healthcare provider.
- C. Schedule an ultrasound.
- D. Obtain hematocrit level.
Correct Answer: B
Rationale: Notifying the healthcare provider about abnormal FHR patterns ensures timely intervention to address potential fetal distress.
The nurse reports the current assessment findings to the healthcare provider (HCP). Based on the assessment findings, the priority diagnosis suspected is preeclampsia. This diagnosis places the client at risk of which complications?
- A. Seizures.
- B. Stroke.
- C. Organ damage.
- D. Preterm birth.
Correct Answer: A,B,C,D
Rationale: Preeclampsia increases risks of seizures (eclampsia), stroke, organ damage (liver/kidneys), and preterm birth due to placental insufficiency.
A new parent asks the nurse about an area of swelling on the baby's head near the posterior fontanel that lies across the suture line. How should the nurse respond?
- A. “That is called caput succedaneum. It will have to be drained.â€.
- B. “That is called a cephalhematoma. It can cause jaundice as it is absorbed.â€.
- C. “That is called a cephalhematoma. It will cause no problems.â€.
- D. “That is called caput succedaneum. It will absorb and cause no problems.â€.
- E. A couple who plan to use in-vitro fertilization with donated sperm.
Correct Answer: D
Rationale: Caput succedaneum is swelling across suture lines that resolves spontaneously, unlike cephalhematoma, which is confined and may cause jaundice.