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The physician orders intermittent fetal heart rate monitoring for a 20-year-old obese primigravid client at 40 weeks' gestation who is admitted to the birthing center in the first stage of labor. The nurse should monitor the client's fetal heart rate pattern at which of the following intervals?
- A. Every 15 minutes during the latent phase.
- B. Every 30 minutes during the active phase.
- C. Every 60 minutes during the initial phase.
- D. Every 2 hours during the transition phase.
Correct Answer: B
Rationale: For a low-risk primigravid client in the active phase of the first stage of labor, intermittent fetal heart rate monitoring is typically performed every 30 minutes to ensure fetal well-being, as per standard obstetric guidelines. More frequent monitoring (every 15 minutes) is reserved for the second stage or high-risk cases, while less frequent intervals (every 60 minutes or 2 hours) are insufficient for active labor.
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The physician who elects to perform a cesarean delivery on a primigravid client for fetal distress has informed the client of possible risks during the procedure. When the nurse asks the client to sign the consent form, the client's husband says, 'I'll sign it for her. She's too upset by what is happening to make this decision.' The nurse should:
- A. Ask the client if this is acceptable to her.
- B. Have the client and her husband both sign the consent form.
- C. Ask the client to sign the consent form.
- D. Ask the doctor to witness the consent form.
Correct Answer: C
Rationale: The client must provide informed consent unless incapacitated. The nurse should ask the client to sign, ensuring she understands despite her distress. The husband cannot sign unless legally authorized, and dual signatures or physician witnessing are unnecessary.
Assessment of a 16-year-old nulligravid client who visits the clinic and asks for information on contraceptives reveals a menstrual cycle of 28 days. The nurse formulates a nursing diagnosis of Deficient knowledge related to ovulation and fertility management. Which of the following would be important to include in the teaching plan for the client?
- A. The ovum survives for 96 hours after ovulation, making conception possible during this time.
- B. The basal body temperature falls at least 0.2°F after ovulation has occurred.
- C. Ovulation usually occurs on day 14, plus or minus 2 days, before the onset of the next menstrual cycle.
- D. Most women can tell they have ovulated because of severe pain and thick, scant cervical mucus.
Correct Answer: C
Rationale: Ovulation typically occurs around day 14 (plus or minus 2 days) before the next menstrual cycle in a 28-day cycle, which is critical for understanding fertility windows. The ovum survives for about 12-24 hours, not 96 hours, and basal body temperature rises after ovulation.
A 30-year-old multigravid client at 8 weeks' gestation has a history of insulin-dependent diabetes since age 20. When explaining about the importance of blood glucose control during pregnancy, the nurse should tell the client that which of the following will occur regarding the client's insulin needs during the first trimester?
- A. They will increase.
- B. They will decrease.
- C. They will remain constant.
- D. They will be unpredictable.
Correct Answer: B
Rationale: Insulin needs typically decrease in the first trimester due to increased insulin sensitivity.
A multigravid client at 34 weeks' gestation with premature rupture of the membranes tests positive for group B streptococcus. The client is having contractions every 4 to 6 minutes. Her vital signs are as follows: blood pressure, 120/80 mm Hg; temperature, 100° F(37.8° C); pulse, 100 bpm; respirations, 18 breaths/minute. Which of the following would the nurse expect the physician to order?
- A. Intravenous penicillin.
- B. Intravenous gentamicin sulfate(Garamycin).
- C. Intramuscular betamethasone(Celestone).
- D. Intramuscular cefaclor(Ceclor).
Correct Answer: A
Rationale: Penicillin is used to treat group B streptococcus.
The nurse on the postpartum mother-baby unit is assigned to take care of four couplets and a new couplet will be admitted within the next 30 minutes. All assessments are complete. The nurse can delegate care for which couplet to the unlicensed nursing personnel?
- A. A G1 P1 with gestational diabetes who is 12 hours postpartum and who still requires insulin.
- B. A G4 P4 who is breast-feeding an 8 lb infant without difficulty.
- C. A G3 P3 postpartum client who is receiving Magnesium Sulfate and whose infant has a respiratory rate of 20.
- D. A G2 P2 who delivered vaginally 2 days ago with an infant having low blood glucose levels the first 24 hours post delivery.
Correct Answer: B
Rationale: The G4 P4 client with stable breastfeeding is appropriate for UAP delegation, as no complex medical needs are present.