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What does optimal nursing care after an amniocentesis include?
- A. Pushing fluids by mouth
- B. Monitoring uterine activity
- C. Placing the patient in a supine position for 2 hours
- D. Applying a pressure dressing to the puncture site
Correct Answer: B
Rationale: The correct answer is B: Monitoring uterine activity. After an amniocentesis, it is crucial to monitor uterine activity to detect any signs of preterm labor or uterine contractions. This helps in identifying any potential complications early on and ensures prompt intervention if needed.
A: Pushing fluids by mouth is important for hydration but not directly related to optimal nursing care after an amniocentesis.
C: Placing the patient in a supine position for 2 hours is not recommended as it may increase the risk of hypotension and discomfort for the patient.
D: Applying a pressure dressing to the puncture site is not necessary after an amniocentesis as the risk of bleeding is minimal and pressure dressings may increase the risk of infection.
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A client with diabetes mellitus is at 37 weeks gestation. She has had weekly NSTs for the last 3 weeks, and the results have been reactive. This week, the NST was nonreactive after 40 minutes. The nurse anticipates which of the following will be performed for the client based on these results?
- A. Scheduled for an immediate ultrasound
- B. Scheduled for a biophysical profile
- C. Admitted to the hospital for induction of labor
- D. Scheduled for a follow-up appointment for NST in 2 days
Correct Answer: B
Rationale: The correct answer is B: Scheduled for a biophysical profile. At 37 weeks gestation, a nonreactive NST after 40 minutes indicates a need for further evaluation with a biophysical profile to assess fetal well-being comprehensively. This test includes NST along with ultrasound evaluation of amniotic fluid volume, fetal tone, fetal breathing movements, and gross body movements. Biophysical profile provides a more detailed assessment of fetal status compared to NST alone.
Choice A is incorrect because an immediate ultrasound is not the next step after a nonreactive NST. Choice C is incorrect because hospital admission for labor induction is premature based on one nonreactive NST result. Choice D is incorrect because waiting for 2 days for a follow-up NST is not recommended due to the urgency of assessing fetal well-being promptly.
A client who had a vaginal delivery 2 hours earlier has just been transferred to the postpartum unit from labor and delivery. Which of the following nursing care goals is of highest priority?
- A. The client will breastfeed her baby every 2 hours.
- B. The client will consume a nutritious diet.
- C. The client will have a moderate lochial flow.
- D. The client will ambulate in the hallways every shift.
Correct Answer: C
Rationale: Ensuring the client has a moderate lochial flow is a priority to monitor for postpartum hemorrhage.
A pregnant patient asks the prenatal nurse how much physical activity is safe during pregnancy. What is an acceptable response by the nurse?
- A. Decreasing physical activity decreases emotional and physical symptoms.
- B. Increasing physical activity increases emotional and physical symptoms.
- C. Physical activity during pregnancy should be limited to hygiene and household tasks.
- D. The level of activity prior to pregnancy is used to determine a safe activity level during pregnancy.
Correct Answer: D
Rationale: The correct answer is D because the level of activity prior to pregnancy is a good indicator of the safe activity level during pregnancy. This is because pregnant women are generally encouraged to continue their pre-pregnancy level of exercise, adjusting as needed based on individual circumstances.
A is incorrect because decreasing physical activity may lead to more physical discomfort and emotional symptoms. B is incorrect as increasing physical activity can be beneficial if done safely. C is incorrect because hygiene and household tasks alone may not provide sufficient physical activity during pregnancy.
The nurse is caring for a client in labor with her third baby. She is 39 weeks gestation, 6 cm dilated, 80% effaced, and 0 station, with minimal variability and recurrent variable decelerations. What action is the highest priority for the nurse?
- A. Administer oxygen
- B. Change maternal position
- C. Perform fetal scalp stimulation
- D. Perform vaginal examination
Correct Answer: B
Rationale: The correct answer is B: Change maternal position. This is the highest priority because the client is experiencing recurrent variable decelerations, which can indicate umbilical cord compression. Changing the maternal position can help relieve the pressure on the cord, potentially improving fetal oxygenation. Administering oxygen (choice A) can be important but addressing the cause of the variable decelerations is crucial. Performing fetal scalp stimulation (choice C) is not appropriate at this time as the focus should be on improving fetal oxygenation. Performing a vaginal examination (choice D) is not necessary at this moment and may even exacerbate the situation.
A baby is born addicted to crack cocaine. Which of the following signs/symptoms would the nurse expect to see?
- A. Hyperreflexia.
- B. Anorexia.
- C. Constipation.
- D. Hypokalemia.
Correct Answer: A
Rationale: Neonates born addicted to crack cocaine often exhibit hyperreflexia, irritability, and other signs of withdrawal.