Nokea
What condition do restlessness, cyanosis, nasal flaring, orthopnea, and use of accessory muscles indicate?
- A. liver failure
- B. alteration in oxygenation
- C. preterm delivery
- D. gestational diabetes
Correct Answer: A
Rationale: The correct answer is B: alteration in oxygenation. Restlessness, cyanosis, nasal flaring, orthopnea, and the use of accessory muscles are all classic signs of respiratory distress, indicating a problem with oxygenation. Liver failure (A) would typically present with jaundice, ascites, and coagulopathy, not respiratory symptoms. Preterm delivery (C) is related to early labor signs, such as contractions and cervical changes. Gestational diabetes (D) would manifest with symptoms like increased thirst, frequent urination, and fatigue, not respiratory distress.
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What is a potential risk associated with prolonged second stage labor?
- A. decreased risk of instrumental delivery
- B. decreased risk of cesarean birth
- C. increased risk of fetal distress
- D. increased risk of rapid delivery
Correct Answer: C
Rationale: The correct answer is C: increased risk of fetal distress. Prolonged second stage labor can lead to decreased oxygen supply to the fetus, causing fetal distress. This can result in adverse outcomes for the baby. Other options are incorrect because prolonged second stage labor is actually associated with an increased risk of instrumental delivery (A), an increased risk of cesarean birth (B), and not rapid delivery (D) as it is a prolonged process.
The patient presenting at 38 weeks' gestation, gravida 1, para 0, vaginal exam 4 cm, 100% effaced, +1 station vertex. What is the most likely intervention for this fetal heart rate pattern?
- A. Continue oxytocin (Pitocin) infusion.
- B. Contact the anesthesia department for epidural administration.
- C. Change maternal position.
- D. Administer Narcan to patient and prepare for immediate vaginal delivery.
Correct Answer: C
Rationale: The correct answer is C: Change maternal position. At 38 weeks' gestation with 4 cm dilation and 100% effacement, the fetal heart rate pattern suggests possible umbilical cord compression due to the +1 station vertex position. Changing maternal position can relieve this compression, improving fetal heart rate. Continuing oxytocin infusion (A) can worsen the situation by increasing contractions. Contacting anesthesia for epidural (B) is not indicated as it doesn't address the immediate concern. Administering Narcan and preparing for immediate delivery (D) is unnecessary and not supported by the given scenario.
What condition is related to an increased risk for fetal demise?
- A. diabetes
- B. migraine headache
- C. spina bifida
- D. thyroid disorder
Correct Answer: A
Rationale: The correct answer is A: diabetes. Diabetes is associated with an increased risk of fetal demise due to complications such as congenital anomalies, macrosomia, and placental insufficiency. High blood sugar levels can lead to adverse effects on the fetus, including stillbirth. Migraine headache (B) and spina bifida (C) are not directly linked to fetal demise. Thyroid disorders (D) can impact pregnancy outcomes but are not specifically associated with an increased risk of fetal demise.
Which nursing action is correct when initiating electronic fetal monitoring?
- A. Lubricate the tocotransducer with an ultrasound gel.
- B. Securely apply the tocotransducer with a strap or belt.
- C. Inform the patient that she should remain in the semi-Fowler position.
- D. Determine the position of the fetus before attaching the electrode to the maternal abdomen.
Correct Answer: D
Rationale: The correct answer is D because determining the position of the fetus before attaching the electrode is crucial for accurate monitoring. This step ensures proper placement, reducing the risk of misinterpretation of data. Lubricating the tocotransducer with gel (A) is unnecessary and may interfere with the signal. Securing the tocotransducer with a strap (B) is important but should come after determining fetal position. Informing the patient to remain in semi-Fowler position (C) is not directly related to the correct initiation of electronic fetal monitoring.
Which clinical finding can be determined only by electronic fetal monitoring?
- A. Variability
- B. Tachycardia
- C. Bradycardia
- D. Fetal response to contractions
Correct Answer: D
Rationale: The correct answer is D because electronic fetal monitoring is the only method that can directly measure and display the fetal heart rate in response to contractions. Variability, tachycardia, and bradycardia can also be observed through electronic fetal monitoring, but fetal response to contractions specifically requires continuous monitoring of the fetal heart rate during contractions. Therefore, D is the only clinical finding that can be determined exclusively through electronic fetal monitoring. Variability (A), tachycardia (B), and bradycardia (C) can be identified through other means of monitoring and assessment as well.