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The nurse’s laboring client is being electronically monitored during her labor. The baseline FHR throughout the labor has been in the 130s. In the last 2 hours, the baseline has decreased to the 100s. How should the nurse document this FHR?
- A. Tachycardia
- B. Bradycardia
- C. Late deceleration
- D. Within normal limits
Correct Answer: B
Rationale: An FHR baseline less than 110 is classified as bradycardia. Tachycardia occurs when the baseline is greater than 160 bpm. A prolonged deceleration is defined as a change from the baseline FHR that occurs for 2 to 10 minutes before returning to baseline. A late deceleration is a gradual decrease and return of the FHR to baseline, associated with a uterine contraction. A decrease to the 100s is not within the normal range. The normal FHR is 120 to 160 bpm.
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The Caucasian postpartum client asks the nurse if the stretch marks (striae gravidarum) on her abdomen will ever go away. Which response by the nurse is most accurate?
- A. “Your stretch marks should totally disappear over the next month.”
- B. “Your stretch marks will always appear raised and reddened.”
- C. “Your stretch marks will lighten in color with good skin hydration.”
- D. “Your stretch marks will fade to pale white over the next 3 to 6 months.”
Correct Answer: D
Rationale: Stretch marks will fade but will not totally disappear. Stretch marks will fade and will not always appear reddened. There is no evidence that keeping the skin hydrated will lighten the appearance of the stretch marks. In Caucasian women, stretch marks will fade to a pale white over 3 to 6 months.
The nurse is caring for the client who just gave birth. Which observation of the client should lead the nurse to be concerned about the client’s attachment to her male infant?
- A. Asking the caregiver about how to change his diaper
- B. Comparing her newborn’s nose to her brother’s nose
- C. Calling the baby “Kelly,” which was the name selected
- D. Repeatedly telling her husband that she wanted a girl
Correct Answer: D
Rationale: Seeking information about infant care is a sign that the mother is developing attachment to her infant. Pointing out family traits or characteristics seen in the newborn is a sign that the mother is developing attachment. Calling the infant by name is a sign that the mother is developing attachment to her infant. Attachment is demonstrated by expressing satisfaction with a baby’s appearance and sex. Frequent expressions of dissatisfaction with the sex of the infant should be concerning and followed up.
Which advice can the nurse give to relieve the client's backache? Select all that apply.
- A. Avoid clothing that fits tightly around the waist.
- B. Sleep on a heating pad.
- C. Take a nonopioid pain reliever regularly.
- D. Wear low-heeled shoes.
- E. Carry objects close to your body.
- F. Squat when picking objects off the floor.
Correct Answer: A,D,E,F
Rationale: Tight clothing, high heels, and improper lifting exacerbate backaches; low-heeled shoes, proper lifting, and loose clothing help relieve strain.
The postpartum client is being admitted for mastitis. The nurse should prepare the client for which interventions? Select all that apply.
- A. Walking at least four times in 24 hours
- B. Receiving a prescribed oral antibiotic
- C. Applying warm packs to the breasts
- D. Getting a prescribed anti-inflammatory drug
- E. Limiting oral fluid intake to 1000 mL per day
- F. Emptying the milk from her breasts frequently
Correct Answer: B,C,D,F
Rationale: Rest is important to promote healing. Bed rest may be initially prescribed for 24 hours. Treatment for mastitis includes administration of antibiotics to treat the infection. Application of warm packs decreases pain and promotes milk flow and breast emptying. Treatment for mastitis includes anti-inflammatory medications to treat fever and decrease breast inflammation. Increasing fluid intake to at least 2 to 3 liters is recommended, not limiting intake. If the breasts continue to be emptied by either breastfeeding or pumping, the duration of symptoms and the incidence of a breast abscess are decreased.
Which response by the nurse is most appropriate?
- A. A weight gain of about 10 pounds is recommended during pregnancy.
- B. Your weight gain depends on the amount of food that you eat.
- C. It's normal for adolescent girls to be worried about weight gain.
- D. You're average weight gain during pregnancy is between 25 and 35 pounds.
Correct Answer: D
Rationale: The average weight gain of 25-35 pounds is appropriate for a teenager with normal prepregnancy weight, addressing her concerns.