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Which action should the nurse take?
- A. Document the normal finding.
- B. Notify the healthcare provider.
- C. Schedule an ultrasound.
- D. Obtain hematocrit level.
Correct Answer: B
Rationale: Notifying the healthcare provider about abnormal FHR patterns ensures timely intervention to address potential fetal distress.
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The nurse observes a fetal heart rate pattern on the monitor: baseline 160 beats per minute with minimal variability, a decrease to 150 beats per minute beginning after the contraction starts and returns to baseline after the contraction ends. Which finding should the nurse document in the electronic medical record?
- A. Variable decelerations.
- B. Late decelerations.
- C. No decelerations.
- D. Early decelerations.
Correct Answer: B
Rationale: The described pattern matches late decelerations, indicating potential utero-placental insufficiency, as the fetal heart rate decreases after the contraction starts and recovers post-contraction.
Following an amniocentesis, a client verbalizes several concerns. Which reported finding indicates to the nurse that the client is experiencing a complication from the amniocentesis?
- A. Low back pain with pelvic cramping.
- B. Headache and blurred vision.
- C. Increased fetal movement.
- D. Epigastric pain.
Correct Answer: A
Rationale: Low back pain and pelvic cramping post-amniocentesis may signal complications like premature labor or infection, requiring immediate evaluation.
A nurse is conducting a preconception class for a group of parents who are anticipating having children. Which client(s) should the nurse refer for genetic counseling? (Select all that apply)
- A. A couple who express concern about birth defects after using an internet DNA testing site.
- B. A woman and her significant other who are excited about the prospect of having children.
- C. A woman planning to start a second family after the loss of an embryo following an in-vitro fertilization procedure.
- D. A man who states that his father was recently diagnosed with Huntington's disease.
- E. A couple who plan to use in-vitro fertilization with donated sperm.
Correct Answer: A,C,D,E
Rationale: Concerns about birth defects, embryo loss, Huntington's disease, and donor sperm use indicate potential genetic risks requiring counseling, unlike general excitement about having children.
The client has experienced an eclamptic seizure. Which of the following interventions by the nurse will help stabilize the client? (Select all that apply)
- A. Explaining procedures.
- B. Treating nausea.
- C. Ensuring side rails are padded.
- D. Assisting with breast pumping.
- E. Evaluating blood pressure frequently.
- F. Evaluating for headache.
- G. Assessing deep tendon reflexes.
Correct Answer: C,E,G,H
Rationale: Padded side rails, frequent blood pressure checks, reflex assessment, and minimizing visitors stabilize the client by preventing injury, monitoring hypertension, and reducing seizure triggers.
A woman at 36-weeks gestation who is Rh negative is admitted to labor and delivery reporting abdominal cramping. She is placed on strict bedrest and the fetal heart rate and contraction pattern are monitored with an external fetal monitor. Two hours after admission, the nurse notes a large amount of bright red vaginal bleeding. Which nursing intervention has the highest priority?
- A. Confirm Rh and Coombs status for Rho(D) immunoglobulin administration.
- B. Perform sterile vaginal examination to determine dilatation.
- C. Assess the fetal heart rate and client's contraction pattern.
- D. Determine fetal position by performing Leopold maneuvers.
Correct Answer: C
Rationale: Bright red vaginal bleeding suggests possible placental issues; assessing fetal heart rate and contraction pattern is critical to detect fetal distress and guide urgent interventions.