Nokea
Which finding in a laboring mother requires immediate intervention?
- A. Contractions occurring every 5 minutes
- B. Late decelerations on fetal heart monitor
- C. Early decelerations on fetal heart monitor
- D. Elevated maternal temperature during labor
Correct Answer: D
Rationale: The correct answer is D: Elevated maternal temperature during labor. This finding indicates a potential infection, such as chorioamnionitis, which can be harmful to both the mother and the baby if not promptly treated. Immediate intervention is necessary to prevent complications like sepsis.
Contractions every 5 minutes (A) are within the normal range for active labor. Late decelerations (B) can indicate uteroplacental insufficiency and require monitoring but not immediate intervention unless persistent. Early decelerations (C) are usually benign and do not typically require immediate action.
You may also like to solve these questions
A nurse is teaching a client who is at 41 weeks of gestation about a non-stress test. Which of the following information should the nurse include in the teaching?
- A. "This test will confirm fetal lung maturity ".
- B. "This test will determine adequacy of placental perfusion".
- C. "This test will detect fetal infection".
- D. "This test will predict maternal readiness for labor".
Correct Answer: B
Rationale: The correct answer is B: "This test will determine adequacy of placental perfusion." The non-stress test is used to assess fetal well-being by monitoring fetal heart rate in response to fetal movement. It helps determine if the placenta is providing enough oxygen and nutrients to the fetus. This information is crucial in assessing the overall health and viability of the fetus.
A: "This test will confirm fetal lung maturity" - This statement is incorrect because the non-stress test does not assess fetal lung maturity. That is usually done through tests like amniocentesis.
C: "This test will detect fetal infection" - This statement is incorrect because the non-stress test does not detect fetal infection. Other tests like amniocentesis or blood tests are used for this purpose.
D: "This test will predict maternal readiness for labor" - This statement is incorrect as the non-stress test focuses on fetal well-being and does not predict maternal readiness for labor.
A nurse is giving post-op teaching to a person after a surgical abortion. What education should be provided?
- A. Report bleeding that is heavy, soaks more than two pads per hour for 2 hours.
- B. You can resume vaginal coitus the next day.
- C. You do not need to return to the clinic for follow-up.
- D. You should use tampons if your bleeding is heavy.
Correct Answer: A
Rationale: The correct answer is A because heavy bleeding post-surgical abortion can indicate a complication like hemorrhage, so prompt reporting is crucial. Choice B is incorrect as resuming vaginal intercourse too soon can increase the risk of infection. Choice C is incorrect because follow-up care is essential to monitor for complications. Choice D is incorrect as tampons should be avoided to reduce the risk of infection. In summary, choice A is correct as it prioritizes patient safety and early detection of complications.
A client at 20 weeks' gestation asks about fetal movements. What is the nurse's best response?
- A. Fetal movements are rarely felt before 24 weeks.
- B. You should feel strong, regular movements at this stage.
- C. You may feel fluttering movements, known as quickening.
- D. It is too early to feel any fetal movements.
Correct Answer: C
Rationale: The correct answer is C because quickening, described as fluttering movements, is typically felt by pregnant individuals around 18-20 weeks of gestation. This indicates fetal movement and is an important milestone in pregnancy. Choices A and D are incorrect as fetal movements can be felt as early as 18-20 weeks. Choice B is incorrect as feeling strong, regular movements is not expected until later in the pregnancy.
A client at 10 weeks' gestation reports frequent nausea. What dietary recommendation should the nurse provide?
- A. Avoid eating salty snacks.
- B. Drink fluids between meals.
- C. Consume three large meals a day.
- D. Avoid eating protein-rich foods.
Correct Answer: B
Rationale: The correct answer is B: Drink fluids between meals. This recommendation helps manage nausea during pregnancy by preventing dehydration, which can worsen symptoms. Consuming fluids between meals also helps maintain hydration and prevents an empty stomach, which can trigger nausea. A: Avoiding salty snacks is not directly related to managing nausea. C: Consuming three large meals a day may worsen nausea due to overeating. D: Avoiding protein-rich foods is not recommended as they are important for fetal development and overall nutrition during pregnancy.
A nurse is providing nutritional guidance to a client who is pregnant and follows a vegan diet. The client asks the nurse which foods she should eat to ensure adequate calcium intake. The nurse should instruct the client that which of the following foods has the highest amount of calcium?
- A. ½ cup cubed avocado
- B. 1 large banana
- C. 1 medium potato
- D. 1 cup cooked broccoli
Correct Answer: D
Rationale: The correct answer is D: 1 cup cooked broccoli. Broccoli is a good source of calcium, with approximately 70 mg per cup. This is higher than the other options provided. Avocado, banana, and potato are not significant sources of calcium compared to broccoli. Broccoli is a suitable choice for a pregnant vegan to ensure adequate calcium intake. It is important for the client to consume a variety of plant-based calcium-rich foods to meet their nutritional needs during pregnancy.