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Which fetal heart rate must the nurse report immediately to the physician?
- A. 100 beats/minute
- B. 120 beats/minute
- C. 140 beats/minute
- D. 160 beats/minute
Correct Answer: A
Rationale: A fetal heart rate of 100 beats/minute is below the normal range (110-160 bpm) and may indicate fetal distress, requiring immediate reporting.
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The nurse assesses the fundal height for multiple pregnant clients. For which client should the nurse conclude that a fundal height measurement is most accurate?
- A. The pregnant client with uterine fibroids
- B. The pregnant client who is obese
- C. The pregnant client with polyhydramnios
- D. The pregnant client experiencing fetal movement
Correct Answer: D
Rationale: Excessive fetal movement may make it difficult to measure the client’s fundal height; however, it should not cause an inaccuracy in the measurement. Fibroids can increase fundal height and give a false measurement. Obesity can increase fundal height and give a false measurement. Polyhydramnios can increase fundal height and give a false measurement.
Which statement by the client indicates a need for further psychosocial support?
- A. I feel ready to bond with my baby.
- B. I am excited about becoming a mother.
- C. I feel worthless and overwhelmed daily.
- D. I have a great support system at home.
Correct Answer: C
Rationale: Feeling worthless and overwhelmed daily suggests potential depression, indicating a need for additional psychosocial support.
The nurse considers prenatal teaching successful when the class correctly identifies which of the following as a danger sign of pregnancy?
- A. Headache and swelling of the face and fingers
- B. Constipation and flatulence on a regular basis
- C. Lower extremity muscle cramping and varicosities
- D. Large amounts of odorless, colorless vaginal secretions
Correct Answer: A
Rationale: Headache and swelling of the face and fingers may indicate preeclampsia, a serious condition requiring immediate attention.
The client with mastitis asks the nurse if she should stop breastfeeding because she has developed a breast infection. Which response by the nurse is best?
- A. “Continuing to breastfeed will decrease the duration of your symptoms.”
- B. “Breastfeeding should only be continued if your symptoms decrease.”
- C. “Stop feeding for 24 hours until antibiotic therapy begins to take effect.”
- D. “It is best to stop breastfeeding because the infant may become infected.”
Correct Answer: A
Rationale: Continuing to breastfeed is recommended when the client has mastitis. If the breasts continue to be emptied by either breastfeeding or pumping, the duration of symptoms and the incidence of a breast abscess are decreased. Continuing to breastfeed will decrease the symptoms of mastitis; there is no need to wait for symptoms to decrease. Usually an oral penicillinase-resistant penicillin or cephalosporin that is safe for the infant while breastfeeding is given to treat mastitis. There is no need for the client to stop breastfeeding for 24 hours. The infant’s nose and throat are the most common sources of the organism that causes mastitis. Infants of women with mastitis generally remain well; thus, concern that the mother will infect the infant if she continues breastfeeding is unwarranted.
The nurse is counseling the pregnant client who has painful hemorrhoids. Which initial recommendation should be made by the nurse?
- A. Apply steroid-based creams.
- B. Modify the diet to include more fiber.
- C. Treat these surgically before delivery.
- D. Increase intake of foods with flavonoids.
Correct Answer: B
Rationale: An initial recommendation should be a high-fiber diet because high-fiber foods increase intestinal bulk and make passage of stool easier. Steroid-based creams are frequently used for hemorrhoids, although evidence does not support their effectiveness. Surgical intervention to remove hemorrhoids is not recommended in pregnancy because hemorrhoids frequently resolve after pregnancy. Flavonoids aid in symptom relief, although they are not recommended as the first line of treatment.