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Vacuum extraction birth
While assisting with a vacuum extraction birth, what should the nurse immediately report to the physician?
- A. Maternal pulse rate of 100 bpm.
- B. Maternal blood pressure of 120/70 mm Hg.
- C. Decrease in intensity of uterine contractions.
- D. Persistent fetal bradycardia below 100 bpm.
Correct Answer: D
Rationale: Persistent fetal bradycardia below 100 bpm indicates potential fetal distress, requiring immediate reporting to ensure fetal safety.
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2-day-old newborn
The nurse explains to the parents of a 2-day-old newborn that decreased life span of neonatal red blood cells has contributed to which complication?
- A. Hyperbilirubinemia.
- B. Respiratory distress syndrome.
- C. Polycythemia.
- D. Transient tachypnea.
Correct Answer: A
Rationale: The increased breakdown of neonatal red blood cells, which have a shorter lifespan, produces bilirubin, leading to hyperbilirubinemia and potential jaundice.
Laboring woman
The most appropriate time for the nurse to encourage a laboring woman to push is during
- A. the interval between contractions.
- B. whenever she feels the need.
- C. second-stage of labor.
- D. first-stage of labor.
Correct Answer: C
Rationale: The second stage of labor, when the cervix is fully dilated, is the appropriate time to push, as contractions are strong and effective for delivery.
Client receiving oxytocin (Pitocin) infusion
The priority nursing care associated with an oxytocin (Pitocin) infusion is:
- A. Measuring urinary output.
- B. Evaluating cervical dilation.
- C. Increasing infusion rate every 30 minutes.
- D. Monitoring uterine response.
Correct Answer: D
Rationale: Monitoring uterine response is critical as oxytocin can cause excessive contractions, risking fetal distress, uterine rupture, or placental abruption.
Newborn reflex observation
What reflex is elicited: Fanning of toes when stroking lateral edge of baby's foot?
- A. Babinski's Reflex.
- B. Stepping Reflex.
- C. Moro reflex.
- D. Plantar Grasp reflex.
Correct Answer: A
Rationale: Babinski's Reflex is elicited by fanning of the toes when the lateral edge of the foot is stroked, normal in infants up to 2 years.
Client in labor, external fetal monitor, late decelerations
A nurse is caring for a client who is in labor and has an external fetal monitor. The nurse observes late decelerations on the monitor strip and interprets them as indicating which of the following?
- A. Uteroplacental insufficiency.
- B. Umbilical cord compression.
- C. Maternal bradycardia.
- D. Fetal head compression.
Correct Answer: A
Rationale: Late decelerations indicate uteroplacental insufficiency, where reduced placental blood flow during contractions causes fetal hypoxia.