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Which finding indicates a need for further evaluation during a prenatal visit?
- A. Blood pressure of 120/80 mmHg
- B. Trace protein in urine
- C. Weight gain of 1 pound per week
- D. Fetal heart rate of 140 bpm
Correct Answer: B
Rationale: Trace protein in urine may indicate early preeclampsia or kidney issues, warranting further evaluation.
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The nurse reviews information and assesses the laboring client at 42 weeks’ gestation before an HCP induces labor. Which findings should be reported to the HCP because they are contraindications to labor induction? Select all that apply.
- A. Umbilical cord prolapse
- B. Transverse fetal lie
- C. Cervical dilation not progressing
- D. Premature rupture of membranes
- E. Previous cesarean incision
Correct Answer: A,B,E
Rationale: Inducing labor with an umbilical cord prolapsed can cause fetal trauma and is contraindicated. This should be reported to the HCP. Inducing labor with a transverse fetal lie can produce trauma to the fetus and mother and is contraindicated. This should be reported to the HCP. Women with a previous cesarean incision should not be stimulated because it is a contraindication for a vaginal birth and warrants an immediate repeat cesarean birth. This should be reported to the HCP. Lack of progressive cervical dilation is an indication for labor induction, not a contraindication. Premature rupture of the membranes is an indication for labor induction, not a contraindication.
The nurse is caring for four postpartum clients. Which client should be the nurse’s priority for monitoring for uterine atony?
- A. Client who is 2 hours post-cesarean birth for a breech baby
- B. Client who delivered a macrosomic baby after a 12-hour labor
- C. Client who has a firm fundus after a vaginal delivery 4 hours ago
- D. Client receiving oxytocin intravenously for past 2 hours
Correct Answer: B
Rationale: Although the client post—cesarean birth for a breech baby may be at risk for uterine atony and should be monitored, the client who delivered a macrosomic baby is more at risk. This client is the nurse’s priority for monitoring for uterine atony. A macrosomic baby stretches the client’s uterus, and thus the muscle fibers of the myometrium, beyond the usual pregnancy size. After delivery the muscles are unable to contract effectively. A firm fundus indicates that the client’s uterine muscles are contracting. Oxytocin (Pitocin) is being administered to increase uterine contractions. Although prolonged use of oxytocin can result in uterine exhaustion, two hours of use is not prolonged.
The nurse correctly instructs the client to contact the physician immediately under which circumstance?
- A. When the first fetal movement is felt
- B. If the breasts become tender
- C. If vaginal bleeding occurs
- D. When experiencing frequent urination
Correct Answer: C
Rationale: Vaginal bleeding is a danger sign in pregnancy, potentially indicating miscarriage or placental issues, requiring immediate reporting.
On the basis of this finding, the nurse can assume that the client is at least how many months' pregnant?
- A. 5 months
- B. 6 months
- C. 7 months
- D. 8 months
Correct Answer: A
Rationale: Ballottement, the rebound of the fetus when the cervix is tapped, is typically detectable around 4-5 months, indicating at least 5 months' gestation.
Which resource should the nurse recommend for additional prenatal education?
- A. Reputable pregnancy websites
- B. Social media forums
- C. Unverified blogs
- D. Television advertisements
Correct Answer: A
Rationale: Reputable pregnancy websites provide evidence-based information, ensuring accurate and reliable prenatal education.