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Which nursing action is correct when initiating electronic fetal monitoring?
- A. Lubricate the tocotransducer with an ultrasound gel.
- B. Securely apply the tocotransducer with a strap or belt.
- C. Inform the patient that she should remain in the semi-Fowler position.
- D. Determine the position of the fetus before attaching the electrode to the maternal abdomen.
Correct Answer: D
Rationale: The correct answer is D because determining the position of the fetus before attaching the electrode is crucial for accurate monitoring. This step ensures proper placement, reducing the risk of misinterpretation of data. Lubricating the tocotransducer with gel (A) is unnecessary and may interfere with the signal. Securing the tocotransducer with a strap (B) is important but should come after determining fetal position. Informing the patient to remain in semi-Fowler position (C) is not directly related to the correct initiation of electronic fetal monitoring.
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The nurse is making a plan of care for a patient who is in the first 24-hour period past a cesarean delivery. Which interventions will the nurse include in regards to medications? Select all that apply.
- A. Continue a daily stool softener.
- B. Manage pain with morphine.
- C. Ensure the availability of naloxone.
- D. Provide prophylaxis antibiotics.
Correct Answer: C
Rationale: The correct answer is C: Ensure the availability of naloxone. Naloxone is an opioid antagonist used to reverse the effects of opioid overdose, which could occur if the patient is receiving morphine for pain management post-cesarean delivery. It is essential to have naloxone readily available to counteract any potential opioid-related respiratory depression.
A: Continuing a daily stool softener is not directly related to medications typically given post-cesarean delivery and is not a priority in the immediate post-operative period.
B: Managing pain with morphine is a common practice post-cesarean delivery, but the focus here is on the intervention related to medication safety, which is ensuring naloxone availability.
D: Providing prophylactic antibiotics is important post-cesarean delivery to prevent infection but is not directly related to medication safety in this scenario.
What newborn complication does type 1 diabetes mellitus cause?
- A. hyperglycemia
- B. fetal macrosomia
- C. group B strep
- D. cyanosis
Correct Answer: C
Rationale: The correct answer is C: group B strep. Women with type 1 diabetes are at higher risk of developing infections, including group B strep, which can be passed to the newborn during childbirth. This can lead to serious complications such as pneumonia, sepsis, and meningitis in the newborn. Hyperglycemia (choice A) is a common complication of maternal diabetes but is not specific to type 1 diabetes. Fetal macrosomia (choice B) is a condition where the baby is larger than average, which can be a complication of diabetes but not specific to type 1. Cyanosis (choice D) refers to a bluish discoloration of the skin due to lack of oxygen and is not directly related to type 1 diabetes complications in newborns.
The nurse is educating a gravida 1 para 0 who is 28 weeks pregnant. Which educational topics are appropriate for the nurse to discuss with the patient at this prenatal visit? Select all that apply.
- A. Discussion of prenatal classes
- B. Discussion of alcohol use
- C. Discussion of family history for pregnancy-induced hypertension
- D. Discussion of signs and symptoms of preterm labor
Correct Answer: B
Rationale: The correct answer is B, Discussion of alcohol use. This topic is important for prenatal education to ensure the well-being of the mother and baby. Alcohol consumption during pregnancy can lead to fetal alcohol spectrum disorders. The other choices are incorrect because:
A: Discussion of prenatal classes is relevant, but not a priority at 28 weeks.
C: Discussion of family history for pregnancy-induced hypertension is important but not usually discussed at every prenatal visit.
D: Discussion of signs and symptoms of preterm labor is crucial, but typically discussed later in pregnancy.
The nurse is preparing supplies for an amnioinfusion on a patient with intact membranes. Which supplies should the nurse gather? (Select all that apply.)
- A. Extra underpads
- B. Solution of 3% normal saline
- C. Amniotic hook to perform an amniotomy
- D. Solid intrauterine pressure catheter with a pressure transducer on its tip
Correct Answer: A
Rationale: The correct answer is A: Extra underpads. For an amnioinfusion on a patient with intact membranes, extra underpads are necessary to absorb any excess fluid leakage during the procedure. The other choices are incorrect because:
B: Solution of 3% normal saline is not necessary for an amnioinfusion with intact membranes as there is no need for amniotic fluid replacement.
C: Amniotic hook to perform an amniotomy is not required when the patient's membranes are intact; this procedure involves rupturing the membranes.
D: Solid intrauterine pressure catheter with a pressure transducer on its tip is used for monitoring intrauterine pressure during labor, not for an amnioinfusion procedure.
The nurse admits a laboring patient at term. On review of the prenatal record, the patient's pregnancy has been unremarkable and she is considered low risk. In planning the patient's
- A. the fetal heart rate during the first stage of labor?
- B. Every 10 minutes
- C. Every 15 minutes
- D. Every 30 minutes
Correct Answer: C
Rationale: The correct answer is C: Every 15 minutes. This is the appropriate frequency for monitoring the fetal heart rate during the first stage of labor for a low-risk patient. Monitoring every 15 minutes allows for regular assessment of the baby's well-being without being overly invasive. Monitoring every 10 minutes (choice A) would be too frequent and may lead to unnecessary interventions. Monitoring every 30 minutes (choice D) would be too infrequent and could potentially miss important changes in the fetal heart rate. Choice B is not the correct answer because monitoring every 10 minutes is too frequent for a low-risk patient and could lead to unnecessary interventions and increased stress for the laboring patient.