Nokea
A newborn is born to a mother with gestational diabetes. What complication is the nurse most likely to monitor for?
- A. Hypoglycemia
- B. Hyperthermia
- C. Jaundice
- D. Respiratory alkalosis
Correct Answer: A
Rationale: Babies of diabetic mothers risk hypoglycemia due to high insulin.
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A nurse is planning care for a client who is pregnant and has HIV. Which of the following actions should the nurse include in the plan of care?
- A. Instruct the client to stop taking the antiretroviral medication at 32 weeks of gestation.
- B. Use a fetal scalp electrode during labor and delivery.
- C. Administer a pneumococcal immunization to the newborn within 4 hr. following birth.
- D. Bathe the newborn before initiating skin-to-skin contact
Correct Answer: C
Rationale: Administering a pneumococcal immunization to the newborn within 4 hours following birth is a crucial action to include in the plan of care for a pregnant client with HIV. Infants born to HIV-positive mothers are at higher risk for infections, including pneumococcal disease. Administering a pneumococcal vaccine shortly after birth helps protect the newborn from this serious infection. It is important to follow established guidelines for immunizations in newborns of HIV-positive mothers to optimize the infant's health outcomes.
The nurse is educating a client about managing heartburn during pregnancy. What is the best advice?
- A. Lie down immediately after eating.
- B. Eat small, frequent meals.
- C. Drink a glass of water with meals.
- D. Consume spicy foods to aid digestion.
Correct Answer: B
Rationale: Eating small, frequent meals helps prevent reflux and minimizes heartburn during pregnancy.
A nurse is caring for a client who is receiving oxytocin to augment labor. The client has an intrauterine pressure catheter and an internal fetal scalp electrode for monitoring. Which of the following is an indication that the nurse should discontinue the infusion?
- A. Contraction frequency every 3 min
- B. Contraction duration of 100 seconds
- C. Fetal heart rate with moderate
- D. variability Fetal heart rate of 118/min
Correct Answer: B
Rationale: Prolonged contractions lasting more than 90-120 seconds may reduce placental perfusion and oxygenation to the fetus, leading to fetal distress. This can result in fetal hypoxia and compromise. Therefore, if the contraction duration reaches 100 seconds, it is an indication for the nurse to discontinue the oxytocin infusion to prevent harm to the fetus. Monitoring for appropriate contraction duration is crucial to ensure the well-being of both the mother and the fetus during labor. While contraction frequency every 3 minutes, a fetal heart rate with moderate variability, and a fetal heart rate of 118/min can be normal findings during labor, a prolonged contraction duration is a concerning sign that requires immediate intervention.
A nurse midwife is examining a client who is a primigravida at 42 weeks of gestation and states that she believes she is in labor. Which of the following findings confirm to the nurse that the client is in labor
- A. Cervical dilation
- B. Report of pain above the umbilicus
- C. Brownish vaginal discharge
- D. Amniotic fluid in the vaginal vault
Correct Answer: A
Rationale: Cervical dilation is a key physiological change that confirms labor has begun. During the late stages of pregnancy, the cervix starts to soften, thin out (efface), and open up (dilate) in preparation for childbirth. Therefore, cervical dilation is a critical finding that indicates the onset of labor. Pain above the umbilicus, brownish vaginal discharge, and amniotic fluid in the vaginal vault are not definitive signs of labor and do not confirm the initiation of the labor process.
The nurse is caring for a postpartum client who is
- A. Maternal hyperglycemia 1 day postcesarean birth. What assessment data
- B. FHR, early decelerations would indicate infection? Select all that apply.
- C. FHR, late decelerations
- D. Increased pulse
Correct Answer: A
Rationale: Maternal hyperglycemia 1 day post-cesarean birth can indicate infection. Hyperglycemia can impair immune function and make the body more susceptible to infections.