Nokea
Which intervention would the nurse initiate when a fetal heart pattern signifying uteroplacental insufficiency occurs?
- A. Inserting a urinary catheter
- B. Administering oxygen by means of nasal cannula
- C. Helping the client turn to the side-lying position
- D. Encouraging the client to pant with her next contraction
Correct Answer: C
Rationale: The correct answer is C: Helping the client turn to the side-lying position. This intervention facilitates increased blood flow to the placenta, improving oxygenation to the fetus during uteroplacental insufficiency. The side-lying position relieves pressure on the vena cava, enhancing blood flow. Inserting a urinary catheter (A) is not indicated for addressing uteroplacental insufficiency. Administering oxygen (B) is important, but turning the client to the side is the priority as it directly improves blood flow. Encouraging panting (D) is not effective in addressing uteroplacental insufficiency.
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The nurse applies fetal and uterine monitors to the abdomen of a client in active labor. When the client has contractions, the nurse notes a 15 beats/min deceleration of the fetal heart rate below the baseline lasting 15 seconds. Which is the next nursing action?
- A. Calling the primary health care provider
- B. Changing the maternal position
- C. Obtaining the maternal blood pressure
- D. Preparing the environment for an immediate birth
Correct Answer: B
Rationale: The correct answer is B: Changing the maternal position. Deceleration of fetal heart rate during contractions can indicate umbilical cord compression. Changing the maternal position can relieve pressure on the cord, improving blood flow to the fetus. This action is a non-invasive and immediate intervention that can potentially improve fetal oxygenation. Calling the primary health care provider (A) can be done after addressing the immediate concern. Obtaining maternal blood pressure (C) is not the priority in this situation. Preparing for an immediate birth (D) is premature without first attempting non-invasive interventions.
A patient at 32 weeks' gestation is diagnosed with polyhydramnios. The patient asks the nurse if polyhydramnios can affect the baby. What is the nurse's response to the patient's question?
- A. No, polyhydramnios commonly occurs toward the end of pregnancy.
- B. No, polyhydramnios is a sign that the lungs are maturing.
- C. Yes, polyhydramnios increases the risk of a preterm delivery.
- D. Yes, polyhydramnios causes umbilical cord compression.
Correct Answer: C
Rationale: The correct answer is C: Yes, polyhydramnios increases the risk of a preterm delivery. Polyhydramnios, an excess of amniotic fluid, can lead to uterine overdistension, which may trigger premature labor. The increased pressure from the excess fluid can also cause premature rupture of membranes. This complication can potentially result in a preterm delivery, which carries risks for the baby's health and development. Choices A and B are incorrect because polyhydramnios is not a normal occurrence at the end of pregnancy nor a sign of lung maturity. Choice D is incorrect as umbilical cord compression is a potential complication of polyhydramnios but not the primary risk associated with it.
Several hours after delivery, a new mother expresses ambivalence regarding her infant. How will the nurse promote bonding?
- A. Having the mother feed the infant
- B. Removing the infant from the mother's arms if it cries
- C. Positioning the infant so its head rests on the mother's shoulder
- D. Encouraging the mother to sleep for 4 to 6 hours before interacting with the infant
Correct Answer: A
Rationale: The correct answer is A, having the mother feed the infant. This helps promote bonding through physical closeness, eye contact, and the release of oxytocin. Feeding also fosters a sense of responsibility and nurturing. Choice B may disrupt bonding by creating separation anxiety. Choice C is a comforting position but not as interactive as feeding. Choice D delays bonding and can impact the establishment of a strong maternal-infant relationship.
The health-care provider is caring for an adolescent patient who is pregnant. The health-care provider knows that pregnancy during adolescence is linked with what influencing factor or factors? Select all that apply.
- A. low socioeconomic status
- B. psychologic problems
- C. social problems
- D. unemployment
Correct Answer: A,B,C
Rationale: A: Low socioeconomic status is a contributing factor to adolescent pregnancy due to limited access to education, healthcare, and contraception. B: Psychologic problems such as low self-esteem or mental health issues can increase the likelihood of adolescent pregnancy. C: Social problems like lack of support from family or peers, or exposure to risky behaviors, can also influence adolescent pregnancy. D: Unemployment, while a potential issue, is not directly linked to adolescent pregnancy as the other factors are more significant in this context.
What is a common sign or symptom of preeclampsia during pregnancy?
- A. abdominal cramps
- B. severe headache
- C. increased appetite
- D. elevated heart rate
Correct Answer: B
Rationale: The correct answer is B: severe headache. A common sign of preeclampsia is a severe headache due to high blood pressure, a hallmark symptom of the condition. Preeclampsia can lead to dangerous complications for both the mother and the baby. Abdominal cramps (A) are not typically associated with preeclampsia. Increased appetite (C) is not a typical symptom and may even decrease due to other factors. Elevated heart rate (D) is not a specific sign of preeclampsia; high blood pressure is the key indicator.