The nurse should identify which of the following conditions as a possible cause of fetal bradycardia?
- A. Chorioamnionitis
- B. Maternal fever
- C. Fetal anemia
- D. Maternal hypoglycemia
Correct Answer: D
Rationale: Maternal hypoglycemia can lead to fetal bradycardia.
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A nurse is assessing a client who is in active labor. Which of the following findings should the nurse report to the provider?
- A. Temperature 37.4° C(99,3° F)
- B. Early decelerations in the FHR
- C. FHR baseline 170/min
- D. Contractions lasting 80 seconds
Correct Answer: C
Rationale: The correct answer is C: FHR baseline 170/min. A baseline fetal heart rate (FHR) of 170/min is considered tachycardia and may indicate fetal distress. The nurse should report this finding to the provider for further evaluation and intervention. Early decelerations in fetal heart rate (choice B) are generally considered normal and do not require immediate reporting. A slightly elevated temperature (choice A) may not be concerning during labor. Contractions lasting 80 seconds (choice D) can be normal in active labor.
Which of the following current clients should the nurse recommend for early discharge?
- A. A client who is receiving heparin for deep- vein thrombosis
- B. A client who has COPD and a respiratory rate of 44/min
- C. A client who has cancer and a sealed implant for radiation therapy
- D. A client who is 1 day postoperative following a vertebroplasty
Correct Answer: D
Rationale: Stable postoperative clients can be discharged safely.
The nurse should identify that which of the following client findings requires follow-up care?
- A. A client who is taking bumetanide and has a potassium level of 3.6 mEq/L
- B. A client who is scheduled for a colonoscopy and is taking sodium phosphate
- C. A client who is taking warfarin and has an INR of 1.8
- D. A client who received a Mantoux test 48 hr ago and has an induration
Correct Answer: C
Rationale: The correct answer is C. A client taking warfarin with an INR of 1.8 requires follow-up care as the INR is subtherapeutic, increasing the risk of clot formation. A therapeutic INR for clients on warfarin is typically between 2-3. Options A, B, and D do not require immediate follow-up care. A potassium level of 3.6 mEq/L is within the normal range. Sodium phosphate for a colonoscopy preparation is appropriate. An induration after a Mantoux test is an expected finding.
The nurse should monitor the client for which of the following complications?
- A. Contractions
- B. Hypertension
- C. Epigastric pain
- D. Vomiting
Correct Answer: A
Rationale: Contractions can indicate preterm labor, a potential complication after amniocentesis.
To prevent a compromise in placental blood flow during the intraoperative period, which of the following actions should the nurse take?
- A. Position the client in reverse Trendelenburg
- B. Place a wedge under one of the client's hips.
- C. Assist the client into the lithotomy position.
- D. Insert a pillow under the clients frees
Correct Answer: B
Rationale: Hip wedges optimize maternal blood flow.