Nokea
The nurse receives a phone call from a patient concerned about the results of the laboratory tests obtained at the first prenatal visit 10 days ago. What is the nurse's next action?
- A. ask the patient if they have checked their electronic chart
- B. inform the patient they will need to wait until the next office visit for the results
- C. provide the patient with the results of the tests
- D. verify the identification of the patient
Correct Answer: D
Rationale: The correct answer is D: verify the identification of the patient. This is crucial to ensure patient safety and confidentiality. By verifying the patient's identity, the nurse can confirm they are providing the correct information to the right person, preventing potential errors or breaches of confidentiality. Asking about the electronic chart (A) is unnecessary if the identity is not confirmed. Informing the patient to wait (B) does not address the immediate concern. Providing results (C) without proper identification can lead to miscommunication. Hence, verifying the patient's identification is the first step to address the patient's concerns effectively.
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The nurse is teaching a woman how to do the pelvic tilt exercise. In the teaching session, which of the following should the nurse tell the woman to do?
- A. Stand with the back of her heels and shoulders touching a wall.
- B. Bend laterally back and forth from one side to the other.
- C. Move so that her back alternately is concave and convex.
- D. Lie flat on her back and move her hips from side to side.
Correct Answer: C
Rationale: Pelvic tilt exercises involve alternating the back between concave and convex positions to strengthen the lower back and abdominal muscles.
The nurse is preparing to teach a client how to perform daily fetal kick counts. Which instruction is most important for the nurse to give the client?
- A. Count fetal kicks prior to eating a meal
- B. Lie on back when counting kicks
- C. Call provider if at least three movements are not felt in 1 hour
- D. Count all movements over 1 hour
Correct Answer: C
Rationale: The correct answer is C: Call provider if at least three movements are not felt in 1 hour. This instruction is crucial because decreased fetal movements can indicate potential fetal distress. By advising the client to contact the healthcare provider if fewer than three movements are felt in an hour, the nurse is emphasizing the importance of promptly seeking medical attention when there may be a concern for the baby's well-being.
A: Counting kicks prior to eating a meal is not as important as monitoring the baby's movements consistently throughout the day.
B: Lying on the back when counting kicks is not recommended, as it can reduce blood flow to the uterus and potentially affect the baby.
D: Counting all movements over 1 hour may not capture a decrease in movements that could be a cause for concern, as the focus should be on monitoring a specific minimum number of movements within a set timeframe.
In summary, the correct answer emphasizes the need for prompt action in case of decreased fetal movements, while
The nurse is teaching her client about the methods of electronic fetal monitoring during labor. Her client asks which method has the fewest risks to her baby and allows her the most freedom. What is the most appropriate response by the nurse?
- A. Internal and external monitoring have equal risks. You will have to remain in the bed with both of these methods.'
- B. Internal monitoring is a more invasive method, but we only use internal monitoring if we have difficulty obtaining accurate information with external monitoring.'
- C. External monitoring will allow you the most freedom of movement and does not require any invasive procedures for you or your baby.'
- D. External monitoring is not invasive but you have to remain in the bed.'
Correct Answer: C
Rationale: The correct answer is C because external monitoring allows the client the most freedom of movement and does not require any invasive procedures for her or the baby. External monitoring involves placing sensors on the abdomen to monitor the baby's heart rate and the mother's contractions. This method is non-invasive and allows the mother to move around during labor, promoting comfort and mobility.
Choice A is incorrect because internal monitoring is more invasive than external monitoring. Choice B is incorrect because internal monitoring is not used solely based on difficulty obtaining accurate information with external monitoring. Choice D is incorrect because external monitoring does not require the mother to remain in bed; she can move around freely.
A mother, 39 weeks’ gestation, is admitted to the labor suite with rupture of membranes 15 minutes earlier and contractions q 8 minutes × 30 seconds. On vaginal exam, the cervix is 4 cm dilated and 80% effaced, and the station is –2. The baby is found to be in the LSP position. The fetal heart rate is 144 with average variability and variable decelerations. Which of the following complications of labor must the nurse assess this client for at this time?
- A. Precipitous delivery.
- B. Chorioamnionitis.
- C. Uteroplacental insufficiency.
- D. Prolapsed cord.
Correct Answer: D
Rationale: LSP (left sacrum posterior) position and rupture of membranes increase the risk of a prolapsed umbilical cord, which is a medical emergency.
The nurse is performing Leopold's maneuvers on a pregnant patient at 36 weeks of gestation and determines the fetal lie is longitudinal, palpates the fetal legs in the top of the uterus, and palpates the fetal head above the symphysis pubis. Which fetal presentation does the nurse document in the EHR?
- A. cephalic
- B. compound
- C. transverse
- D. breech
Correct Answer: D
Rationale: The correct answer is D: breech. At 36 weeks of gestation, if the nurse palpates the fetal head above the symphysis pubis and the fetal legs are at the top of the uterus, it indicates a breech presentation where the baby's buttocks or feet are positioned to be delivered first. In a breech presentation, the fetal head is not engaged in the pelvis and is palpable above the symphysis pubis. The longitudinal lie with the fetal legs on top further supports the breech presentation.
Summary:
A: Cephalic presentation would have the fetal head engaged in the pelvis.
B: Compound presentation involves an additional body part alongside the presenting part.
C: Transverse lie would have the baby positioned horizontally across the uterus.
D: Breech presentation aligns with the given scenario of palpating fetal legs on top and head above the symphysis pubis.