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Vital Signs: Blood pressure 132/82 mm Hg, Heart rate 82/min, Respiratory rate 16/min, Temperature 37.1°C (98.8°F), Oxygen saturation 98% on room air. Nurses' Notes: Client reports, 'My baby is not moving as much as usual.' Fetal heart rate 142/min with minimal variability, no accelerations noted in 20 min. External fetal monitor applied, uterine contractions every 5 to 7 min lasting 50 to 60 sec, moderate intensity.
Which of the following actions should the nurse take next? Select all that apply.
- A. Assist the client to a lateral position
- B. Increase the rate of maintenance IV fluid.
- C. Palpate uterine tone to assess for tachysystole
- D. Initiate oxytocin intravenously.
- E. Perform a vaginal exam.
Correct Answer: A,B,C
Rationale: Repositioning to a lateral position improves uteroplacental blood flow, increasing IV fluid enhances perfusion, and palpating uterine tone checks for tachysystole, all addressing fetal heart rate deceleration.
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Nurses' Notes: Client at 38 weeks, reports fluid leaking, suspects ruptured membranes. Mild contractions 20 min apart (0630), 15 min apart (0830). Cervix 2 cm dilated, 20% effaced. FHR 132/min with moderate variability. Vital Signs: Temp 37.1°C, HR 93-95/min, RR 13-15/min, BP 130/76-135/78 mm Hg, O2 sat 99-100%.
After review of the client's electronic medical record (EMR), which of the following interventions should the nurse recommend as anticipated, nonessential, or contraindicated?
- A. Perform a Nitrazine test: Anticipated
- B. Check client's temperature every hour: Nonessential
- C. Check FHR every 30 min: Anticipated
- D. Ensure the client maintains a supine position while in bed: Contraindicated
- E. Prepare the client for catheterization: Nonessential
- F. Encourage frequent ambulation: Anticipated
Correct Answer: A,C,F
Rationale: Nitrazine test confirms ruptured membranes, FHR monitoring every 30 min ensures fetal well-being, and ambulation supports labor progression. Hourly temperature checks and catheterization are not necessary, and supine position risks hypotensive syndrome.
A nurse is planning to administer Rho(D) immune globulin to a client who is postpartum.
Which of the following actions should the nurse take?
- A. Administer the medication into the client's abdomen.
- B. Administer the medication within 72 h after birth
- C. Verify that the newborn is Rh-negative
- D. Verify that the client's Coombs test is positive
Correct Answer: B
Rationale: Rho(D) immune globulin should be given within 72 hours after delivery to prevent Rh isoimmunization in an Rh-negative mother with an Rh-positive newborn.
A nurse is checking the reflexes of a newborn.
Which of the following actions should the nurse use to elicit the Babinski reflex?
- A. Stroke upward on the lateral aspect of the sole of the newborn's foot.
- B. Place the newborn supine and apply pressure to the soles of the feet.
- C. Pull the newborn up by the wrist from a supine position
- D. Touch the corner of the newborn's mouth
Correct Answer: A
Rationale: The Babinski reflex is elicited by stroking the lateral sole of the foot, causing dorsiflexion of the big toe and fanning of other toes in newborns.
A nurse is reinforcing teaching with a client who is at 10 weeks of gestation regarding the purposes of laboratory tests.
Which of the following statements by the client indicates an understanding of the teaching?
- A. Urine specific gravity identifies my risk for pregnancy-induced hypertension.
- B. White blood cell count is an indicator of anemia.
- C. Platelet count identifies if I am at risk for bleeding.
- D. Sedimentation rate checks for signs of cancer.
Correct Answer: C
Rationale: Platelet count assesses clotting function, identifying bleeding risk in conditions like gestational thrombocytopenia.
A nurse is contributing to the plan of care for a client who is postpartum and has mastitis.
Which of the following actions should the nurse plan to take?
- A. Limit the client's daily fluid intake
- B. Encourage the client to wear a bra that is loose fitting
- C. Encourage the client to continue to breastfeed.
- D. Prepare the client for an abdominal sonogram
Correct Answer: C
Rationale: Continued breastfeeding prevents milk stasis and reduces the risk of abscess formation in mastitis.