Nokea
Which of the following should the nurse plan to have available when providing nursing care to this client? Select all that apply.
- A. I.V. start kit
- B. An intake and output record
- C. Oxygen and face mask
- D. Cardiac monitor
- E. A consent for a blood transfusion
- F. A suction machine
Correct Answer: A,B,C,F
Rationale: Hyperemesis gravidarum with dehydration requires I.V. fluids, intake/output monitoring, oxygen if needed, and suction for vomiting.
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Which instruction should the nurse provide about postpartum recovery?
- A. Resume heavy exercise immediately
- B. Monitor vaginal bleeding for heavy flow
- C. Avoid bathing for two weeks
- D. Ignore perineal discomfort
Correct Answer: B
Rationale: Monitoring vaginal bleeding for heavy flow is crucial to detect postpartum hemorrhage, a key recovery instruction.
Which laboratory test should the nurse monitor for a client with preeclampsia?
- A. Platelet count
- B. Blood glucose
- C. Cholesterol levels
- D. Thyroid function
Correct Answer: A
Rationale: Monitoring platelet count is critical in preeclampsia, as low platelets may indicate severe disease or HELLP syndrome.
The nurse is caring for the pregnant client whose FHR tracing reveals a reduction in variability over the last 40 minutes. The client has had occasional decelerations after the onset of a contraction that did not resolve until the contraction was over. The client suddenly has a prolonged deceleration that does not resolve, and the nurse immediately intervenes by calling for assistance. Place the nurse’s interventions in the sequence that they should occur.
- A. Administer oxygen via facemask
- B. Have the HCP paged if the prolonged decelerations have not resolved.
- C. Place an indwelling urinary catheter in anticipation of emergency cesarean birth if the heart rate remains low.
- D. Increase the rate of the intravenous (IV) fluids
- E. Assist the client into a different position
- F. Prepare for a vaginal examination and fetal scalp stimulation
Correct Answer: E,A,D,B,F,C
Rationale: Assist the client into a different position should be first. Repositioning is an attempt to increase the FHR in case of cord obstruction. Administer oxygen via facemask is next to increase oxygenation to the fetus. Increase the rate of the IV fluids next to treat possible hypotension, the most common cause of fetal bradycardia. Have the HCP paged if the prolonged decelerations have not resolved. The immediate focus should be on attempting to relieve the prolonged decelerations. Prepare for a vaginal examination and fetal scalp stimulation. This is performed to rule out cord prolapse and to provide stimulation to the fetal head. Place an indwelling urinary catheter in anticipation of emergency cesarean birth if the HR remains low.
Which response by the nurse is best?
- A. Any alcohol consumption during pregnancy will cause the child to have complications later in life.
- B. The minimal safe amount of alcohol consumption during pregnancy has not yet been determined.
- C. Alcohol consumption has a harmful effect on the baby only if consumed during the first trimester of pregnancy.
- D. Occasional intake of a small amount of alcohol during pregnancy will not adversely affect the unborn baby.
Correct Answer: B
Rationale: No safe level of alcohol consumption during pregnancy has been established, as it may cause fetal alcohol spectrum disorders.
Multiple women are being seen in a clinic for various conditions. From which clients should the nurse prepare to obtain a group beta streptococcus (GBS) culture? Select all that apply.
- A. The client who is having symptoms of preterm labor
- B. The women who had a neonatal death 1 year ago
- C. All pregnant women coming to the clinic for care
- D. The women who had a spontaneous abortion 1 week ago
- E. The women who had an abortion for an unwanted pregnancy
Correct Answer: A,C
Rationale: The client in preterm labor should be screened for GBS infection. Between 10% and 30% of all women are colonized for GBS. All pregnant women, regardless of risk status, should be screened for GBS infection. Between 10% and 30% of all women are colonized for GBS. There is no indication that the client with a previous neonatal death is pregnant. The client would not be screened for GBS solely because of a history of spontaneous abortion. The client would not be screened for GBS solely because of an elective abortion.