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When a Category II pattern of the fetal heart rate is noted and the patient is lying on her left side, which nursing action is indicated?
- A. Lower the head of the be
- B. Place a wedge under the left hip.
- C. Change her position to the right side
- D. Place the mother in Trendelenburg position
Correct Answer: C
Rationale: When a Category II pattern of fetal heart rate is noted, placing a wedge under the left hip of the pregnant patient is indicated. This position helps to improve blood flow to the placenta and can sometimes help to improve the fetal heart rate pattern. Placing the patient in a left lateral tilt can also be effective in improving circulation and oxygenation to the fetus. It is important to act promptly in response to abnormal fetal heart rate patterns to optimize the well-being of the baby. Lowering the head of the bed, changing the position to the right side, or placing the mother in Trendelenburg position are not appropriate actions in this situation.
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The nurse is providing care for a prenatal patient who is told she will require a cesarean delivery because of cephalopelvic disproportion. Which explanation of the condition will the nurse provide to the patient?
- A. The patient has a preexisting medical condition that supports cesarean birth.
- B. The size and/or shape of either the fetal head or patient pelvis is an issue.
- C. The placenta is implanted in an unfavorable position in the uterus.
- D. The patient had a surgery with an incision through the myometrium of the uterus.
Correct Answer: B
Rationale: Choice B is the correct answer because cephalopelvic disproportion refers to a situation where the size or shape of the fetal head or the mother's pelvis causes difficulty during vaginal birth. This is the most accurate explanation for why a cesarean may be required.
Proper placement of the tocotransducer for electronic fetal monitoring is
- A. Inside the uterus.
- B. On the fetal scalp.
- C. Over the uterine fundus.
- D. Over the mother's lower abdomen.
Correct Answer: C
Rationale: The tocotransducer is a device used for electronic fetal monitoring to measure uterine contractions. Proper placement of the tocotransducer is over the uterine fundus, which is the upper part of the uterus where contractions are most accurately detected. Placing the tocotransducer there allows for optimal monitoring of uterine activity during labor, ensuring accurate readings and appropriate interventions if necessary. Placing the tocotransducer inside the uterus, on the fetal scalp, or over the mother's lower abdomen would not provide accurate readings of uterine contractions.
The nurse is educating a primigravida patient during her first prenatal clinic appointment about follow-up prenatal care. How often will follow-up prenatal clinic visits be scheduled if the patient has a low-risk pregnancy and develops no complications? Select all that apply.
- A. Every 2 weeks for the first 28 weeks
- B. Every 4 weeks until 30 weeks
- C. Every 4 weeks until 28 weeks
- D. Every 2 weeks after 28 completed weeks until 36 weeks gestation
Correct Answer: C
Rationale: Ballottement is a physical examination technique used to detect the presence of a floating fetus or other abnormalities. A gentle tap on the cervix causes a rebound or sensation, confirming fetal presence.
If the position of a fetus in a cephalic presentation is right occiput anterior, the nurse should assess the fetal heart rate in which quadrant of the maternal abdomen?
- A. Right upper
- B. Left upper
- C. Right lower
- D. Left lower
Correct Answer: C
Rationale: When the fetus is in a right occiput anterior position, the back of the fetus is on the mother's right side, and the fetal heart is also located on the right side of the mother's abdomen. It is typically heard in the lower right quadrant due to the location of the fetal back and heart. The nurse should assess the fetal heart rate in the right lower quadrant of the maternal abdomen to accurately assess the well-being of the fetus in this position.
A pregnant woman is being seen at her first prenatal visit. The RN should correct which action of a student nurse who is preparing the client for a pelvic examination?
- A. Asking the client if she needs something to drink
- B. Assembling the necessary equipment for the pelvic examination
- C. Positioning the client in the lithotomy position
- D. Explaining the procedure prior to the pelvic examination
Correct Answer: A
Rationale: Multipara is a term used for a woman who has given birth more than once, which is consistent with the birth history provided. Primigravida refers to a woman who is pregnant for the first time, and primipara refers to a woman who has had one pregnancy outcome.