Nokea
Which action by the nurse best ensures that an accurate fetal heart rate is obtained?
- A. Assess the fetal heart rate when the client is lying on her right side.
- B. Assess the fetal heart rate when the client reports fetal movement.
- C. Assess the fetal heart rate between Braxton Hicks contractions.
- D. Assess the maternal pulse and fetal heart rate, and compare the two.
Correct Answer: D
Rationale: Comparing maternal pulse with fetal heart rate ensures the nurse is not mistaking the maternal pulse for the fetal heartbeat.
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The 39-year-old client with type 1 DM presents at 36 weeks’ gestation with Drag and Drop contractions. An HCP decides to do an amniocentesis. Which statement best supports why the nurse and NA should prepare the client for an amniocentesis now?
- A. Diabetic women have a higher incidence of birth defects, and the HCP wants to determine if a birth defect is present.
- B. The client is over 35, at 36 weeks’ gestation with Drag and Drop contractions, and is at risk for chromosomal disorders.
- C. An amniocentesis performed at 36 weeks’ gestation is being completed to determine if the fetal lungs have matured.
- D. The amniocentesis is more accurate than the fetal fibronectin test in determining if delivery is imminent.
Correct Answer: C
Rationale: Infants of diabetic mothers are less likely to have mature lung capacity at 36 weeks; knowing lung maturity can influence whether delivery should proceed. In mid pregnancy, the cells in amniotic fluid can be studied for genetic abnormalities such as Down’s syndrome and birth defects, but amniocentesis would not be performed for this purpose when the client is in preterm labor. Many women over the age of 35 have amniocentesis completed to test for chromosomal disorders, but not this late in the pregnancy. Fetal fibronectin testing is used to determine if a preterm birth is likely, but it cannot be used to determine lung maturity.
While assessing the prenatal client, the nurse found a number of concerning problems. Place the concerning problems in the sequence that they should be addressed by the nurse.
- A. Currently bleeding and cramping
- B. Previous varicella infection
- C. Currently using tobacco
- D. Has intense pelvic pain
Correct Answer: D,A,C,B
Rationale: Has intense pelvic pain is most concerning and should be addressed first by the nurse. It could be a symptom of a serious medical condition, such as a miscarriage, ectopic pregnancy, or appendicitis. This symptom represents a possible pathology that could warrant immediate surgical intervention. Currently bleeding and cramping should be addressed next. It could be associated with the pelvic pain and could be a symptom of a serious medical condition, such as a miscarriage or ectopic pregnancy. Currently using tobacco can put the client at risk for multiple adverse outcomes and should be addressed, although it is not an immediately concerning factor. Previous varicella infection is important to document but poses no risk to the client or the fetus, so it is the least important to address.
In the process of preparing the client for discharge after cesarean section, the nurse addresses all of the following areas during discharge education. Which should be the priority advice for the client?
- A. How to manage her incision
- B. Planning for assistance at home
- C. Infant care procedures
- D. Increased need for rest
Correct Answer: B
Rationale: Although the client needs information about incision care, the priority need is for assistance at home so that she can get the rest needed for multiple demands. Because the client has had a surgical procedure, the priority consideration is for the mother to plan for additional assistance at home. Without this assistance, it is difficult for the mother to get the rest she needs for healing, pain control, and appropriate infant care. Infant care is important, but having assistance at home after a surgical procedure is more important. The need for increased rest is important, but she would not be able to obtain adequate rest without assistance at home.
The nurse is providing nutrition counseling to a primigravida who is 10 weeks pregnant. Which meal choice stated by the client indicates she needs additional information?
- A. Black beans, wild rice, collard greens
- B. Dry cereal, milk, dried cranberries
- C. Tuna, broccoli, baked potato
- D. Beef strips, lentils, red peppers
Correct Answer: C
Rationale: Tuna contains mercury and should be limited in pregnancy due to risk of mercury poisoning. The nurse should provide this additional information. Black beans provide a good source of calcium, iron, and protein. Black beans, wild rice, and collard greens provide fiber. Collard greens provide a good source of calcium and folic acid. Dry cereal provides a good source of vitamin D, milk provides a good source of calcium, and dried cranberries provide a good source of calcium and iron. Beef provides a good source of protein and iron, lentils provide a good source of iron, and red peppers provide a good source of vitamin C.
The nurse observes the postpartum multiparous client rubbing her abdomen. When asked if she is having pain, the client says, “It feels like menstrual cramps.” Which intervention should the nurse implement?
- A. Offer a warm blanket for her to place on her abdomen.
- B. Encourage her to lie on her stomach until the cramps stop.
- C. Instruct the client to avoid ambulation while having pain.
- D. Check her lochia flow; pain sometimes precedes hemorrhage.
Correct Answer: B
Rationale: Heat application to the abdomen should be avoided; it may cause uterine muscle relaxation. Multiparous women frequently experience intermittent uterine contractions called afterpains. Lying in a prone position applies pressure to the uterus, stimulating continuous uterine contraction. When the uterus maintains a state of contraction, the afterpains will cease. Ambulation has been shown to decrease muscle pain and should not be avoided. Afterpains are not a symptom of potential postpartum hemorrhage.