Nokea
The pregnant client has been pushing for 2½ hours. After some difficulty, the large fetal head emerges. The HCP attempts to deliver the shoulders without success. Place the nurse’s actions in caring for this client in the correct sequence.
- A. Apply suprapubic pressure per direction of the HCP.
- B. Place the client in exaggerated lithotomy position.
- C. Catheterize the client’s bladder.
- D. Call for the neonatal resuscitation team to be present.
- E. Prepare for an emergency cesarean birth.
Correct Answer: D,B,A,C,E
Rationale: Call for the neonatal resuscitation team to be present because of fetal distress. Place the client in exaggerated lithotomy position so the McRoberts’ maneuver can be performed (flexing her thighs sharply on her abdomen may widen the pelvic outlet and let the anterior shoulder be delivered). Apply suprapubic pressure per direction of the HCP. This is completed in an effort to dislodge the shoulder from under the pubic bone. Catheterize the client’s bladder. This will empty the bladder to make more room for the fetal head. Prepare for an emergency cesarean birth. This will be performed if all efforts for a vaginal birth fail.
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The nurse is caring for the client who has been in the second stage of labor for the last 12 hours. The nurse should monitor for which cardiovascular change that occurs during this stage of labor?
- A. An increase in maternal heart rate
- B. A decrease in the cardiac output
- C. An increase in the white blood cell (WBC) count
- D. A decreased intravascular volume during contractions
Correct Answer: A
Rationale: Maternal HR is normally increased due to pain resulting from increased catecholamine secretion, fear, anxiety, and increased blood volume. When the laboring client holds her breath and pushes against a closed glottis, intrathoracic pressure rises. Blood in the lungs is forced into the left atrium, leading to a transient increase (not decrease) in cardiac output. Although the WBCS increase to 25,000/mm3 to 30,000/mm3 during labor and early postpartum as a physiological response to stress, this is not a cardiovascular change. During the second stage of labor, the maternal intravascular volume is increased (not decreased) by 300 to 500 mL of blood from the contracting uterus.
The pregnant client has an abnormal 1-hour glucose screen and completes a 3-hour, 100-g oral glucose tolerance test (OGTT). Which test results should the nurse interpret as being abnormal?
- A. Fasting blood glucose = 104 mg/dL
- B. 1-hour = 179 mg/dL
- C. 2-hour = 146 mg/dL
- D. 3-hour = 129 mg/dL
Correct Answer: A
Rationale: The fasting blood glucose of 104 mg/dL is abnormal for the OGTT; normal is 95 mg/dL or lower. A 1-hour OGTT value of 179 mg/dL is normal; normal is 180 mg/dL or lower. The 2-hour OGTT value of 146 mg/dL is normal; an abnormal value is 155 mg/dL or higher. The 3-hour OGTT value of 129 mg/dL is normal; an abnormal value is 140 mg/dL or higher.
The client, who delivered a 4200-g baby 4 hours ago, continues to have bright red, heavy vaginal bleeding. The nurse assesses the client’s fundus and finds it to be firm and midway between the symphysis pubis and umbilicus. What should the nurse do next?
- A. Continue to monitor the client’s bleeding and weigh the peripads.
- B. Call the client’s HCP and request an additional visual examination.
- C. Prepare to give oxytocin to stimulate uterine muscle contraction.
- D. Document the findings as normal with no interventions needed at that time.
Correct Answer: B
Rationale: Although the nurse would definitely need to continue to monitor the amount and quality of bleeding, additional intervention is also needed. The nurse should consider the possibility of a vaginal wall or cervical laceration, which could produce heavy, bright red bleeding. The HCP should be notified and asked to perform a visual exam of the vagina to assess for possible lacerations in need of repair. Preparing to administer oxytocin (Pitocin) would be appropriate if the source of bleeding was suspected to be uterine atony, but the uterus is firm and in the expected location. Documenting the findings without further intervention would lead to a failure to identify the source of increased bleeding resulting in possible client injury. Further assessments and interventions are needed.
Interventions have been prescribed by the HCP for the client with decreased fetal movement at 35 weeks’ gestation. Place the prescribed interventions in the sequence that they should be performed by the nurse.
- A. Prepare for a nonstress test
- B. Prepare for a biophysical profile
- C. Palpate for fetal movement
- D. Apply and explain the external fetal monitor
Correct Answer: C,D,A,B
Rationale: Palpate for fetal movement should be performed first. Assessment should be first to verify fetal movement. Apply and explain the external fetal monitor should be next. The fetus should be monitored for heart rate changes. Prepare for an NST. The NST is performed to determine fetal well-being. Prepare for a biophysical profile (BPP). The BPP is an assessment of five fetal biophysical variables: FHR acceleration, fetal breathing, fetal movements, fetal tone, and amniotic fluid volume. The first criterion is assessed with the NST. The other variables are assessed by ultrasound scanning.
The nurse explains to the group that frequent urination during early pregnancy usually subsides at which time?
- A. When the placenta is fully developed
- B. When fetal kidneys begin to function
- C. When the uterus rises into the abdominal cavity
- D. When the hormonal balance is reestablished
Correct Answer: C
Rationale: Frequent urination subsides in the second trimester as the uterus rises into the abdominal cavity, reducing bladder pressure.