OB test #2
The nurse is required to assess a pregnant client who is reporting vaginal bleeding. Which nursing action is the priority? monitoring uterine contractility assessing signs of shock determining the amount of funneling assessing the amount and color of the bleeding
assessing the amount and color of the bleeding Explanation: When the woman arrives and is admitted, assessing her vital signs, the amount and color of the bleeding, and current pain rating on a scale of 1 to 10 are the priorities. Assessing the signs of shock, monitoring uterine contractility, and determining the amount of funneling are not priority assessments when a pregnant woman complaining of vaginal bleeding is admitted to the hospital.
The client is being rushed into the labor and delivery unit. At which station would the nurse document the fetus immediately prior to birth? -5 0 +1 +4
+4 Explanation: As the fetus is being born, the fetus is at +4 station. The fetus is floating and not engaged in the pelvis at -5 station. The fetus is at the level of the ischial spines and engaged at 0 station. The fetus is progressing down the birth canal below the ischial spines at +1 station.
A woman at 26 weeks' gestation is undergoing screening for diabetes with a 1-hour oral glucose challenge test. On the client's return visit, the nurse anticipates the need to schedule a 3-hour glucose challenge test based on which result of the previous test? 100 mg/dL 114 mg/dL 130 mg/dL 146 mg/dL
146 mg/dL Explanation: For a 1-hour glucose challenge test, a 75-g oral glucose load is given, without regard to the timing or content of the last meal. Blood glucose is measured 1 hour later; a level above 140 mg/dL is abnormal. If the result is abnormal, a 3-hour glucose tolerance test is done.
Which nursing action is most appropriate when caring for a child with positive serum IgE antibodies, a white blood cell count of 6,000/mm3, and 10% eosinophils? Review current CD4 counts. Obtain a careful health history. Percuss abdomen for hepatomegaly. Prepare child for stem cell transplant.
Obtain a careful health history. Explanation: The child with positive serum IgE antibodies, a white blood cell count of 6,000/mm3, and 10% eosinophils indicates allergies. Thus, taking a careful history to assess for symptoms and familial tendency is the most appropriate action. Reviewing CD4 counts and percussing for hepatomegaly would be more appropriate if HIV was suspected. Preparing for a stem cell transplant would be more appropriate if severe combined immunodeficiency (SCID) was suspected.
The laboring client who is at 3 cm dilation (dilatation) and 25% effaced is asking for analgesia. The nurse explains the analgesia usually is not administered prior to the establishment of the active phase. What is the appropriate rationale for this practice? This would cause fetal depression in utero. This may prolong labor and increase complications. The effects would wear off before birth. This can lead to maternal hypertension.
This may prolong labor and increase complications. Explanation: Administration of pharmacologic agents too early in labor can stall the labor and lengthen the entire labor. The client should be offered nonpharmacologic options at this point until she is in active labor.
Which procedure is contraindicated in an antepartum client with bright red, painless bleeding? Urinalysis Vaginal examination Leopold maneuver Nonstress test
Vaginal examination Explanation: A vaginal examination is contraindicated in a client with bright red vaginal bleeding until placenta previa is ruled out. The client can have a urinalysis if needed. Leopold maneuver determines fetal position, presentation and attitude. A nonstress test assesses fetal heart rate and movement.
The nurse is providing care to a child with a latex allergy. The nurse notifies all care providers of the allergy and assesses for which early sign of an anaphylactic reaction? Evidence of a wheal or other skin reaction Difficulty breathing Headache Vomiting
Vomiting Explanation: The GI system is the first to be overwhelmed by excessive histamine release.
If a fetus were not receiving enough oxygen during labor because of uteroplacental insufficiency, which pattern would the nurse anticipate seeing on the monitor? a shallow deceleration occurring with the beginning of contractions variable decelerations, too unpredictable to count fetal baseline rate increasing at least 5 mm Hg with contractions fetal heart rate declining late with contractions and remaining depressed
fetal heart rate declining late with contractions and remaining depressed Explanation: Lack of blood supply to the fetus because of poor placental filling prevents the fetal heart rate from recovering immediately following a contraction.
A nurse is teaching a woman in her third trimester about Braxton Hicks contractions. When describing these contractions, which information would the nurse likely include? Select all that apply. "They usually feel like a tightening across the top of your uterus." "They typically last for about 3 minutes each time you have them." "They often spread downward before they go away." "They usually happen in a regular pattern." "They go away when you walk around or change position."
"They usually feel like a tightening across the top of your uterus." "They often spread downward before they go away." "They go away when you walk around or change position." Explanation: Braxton Hicks contractions are typically felt as a tightening or pulling sensation of the top of the uterus. They occur primarily in the abdomen and groin and gradually spread downward before relaxing. In contrast, true labor contractions are more commonly felt in the lower back. These contractions aid in moving the cervix from a posterior position to an anterior position. They also help in ripening and softening the cervix. However, the contractions are irregular and can be decreased by walking, voiding, eating, increasing fluid intake, or changing position. Braxton Hicks contractions usually last about 30 seconds but can persist for as long as 2 minutes. As birth draws near and the uterus becomes more sensitive to oxytocin, the frequency and intensity of these contractions increase. However, if the contractions last longer than 30 seconds and occur more often than four to six times an hour, the woman should be advised to contact her health care provider to be evaluated, especially if she is less than 39 weeks' pregnant.
Which medication will the nurse anticipate the health care provider will prescribe as treatment for an unruptured ectopic pregnancy? oxytocin promethazine ondansetron methotrexate
methotrexate Explanation: Methotrexate, a folic acid antagonist that inhibits cell division in the developing embryo, is most commonly used to treat ectopic pregnancy. Oxytocin is used to stimulate uterine contractions and would be inappropriate for use with an ectopic pregnancy. Promethazine and ondansetron are antiemetics that may be used to treat hyperemesis gravidarum.
The parent of a school-age child comments to the nurse, "Every time my child eats enchiladas at our local Mexican restaurant he gets a rash. It just doesn't make sense to me." How should the nurse respond? "Has your child ever been tested for a peanut allergy?" "Is your child allergic to milk?" "That is odd. Does anyone else in your family react that way?" "Maybe it's an allergy to something else and you just notice after eating there by coincidence."
"Has your child ever been tested for a peanut allergy?" Explanation: Enchilada sauce is an unexpected food that may contain a form of peanuts (such as peanut oil) that may be causing an allergic reaction in the child.
A child's mother asks the nurse how likely it is the child will develop asthma because the child's father has asthma. Which response by the nurse is most appropriate? "Immune responses can be genetic and run in the family." "We don't know why children develop immune disorders." "Asthma can be prevented by avoiding any family allergens." "Your child will develop asthma since the father has asthma."
"Immune responses can be genetic and run in the family." Explanation: The nurse's most appropriate response is to explain that there are familial tendencies with allergic responses but not all family members manifest the symptoms in the same way. For example, if the father has asthma, the child may have allergic rhinitis. Asthma cannot be prevented by avoiding allergens; however, asthma symptoms can be managed by avoiding allergens.
A client at 9 weeks' gestation asks the nurse, "What is a diagonal conjugate?" What is the nurse's best response? "It is the measurement between the ischial tuberosity and the pubis." "It is a measurement to determine if the pelvis size is adequate for a vaginal birth." "It is the smallest diameter of the pelvic outlet." "It is the largest diameter of the pelvic outlet."
"It is a measurement to determine if the pelvis size is adequate for a vaginal birth." Explanation: Since the obstetric conjugate cannot be measured directly, the practitioner must estimate the size. To obtain this estimate, the practitioner measures the diagonal conjugate, which extends from the symphysis pubis to the sacral promontory.
A nurse has been assigned to assess a pregnant client for abruptio placenta. For which classic manifestation of this condition should the nurse assess? painless bright red vaginal bleeding increased fetal movement "knife-like" abdominal pain with vaginal bleeding generalized vasospasm
"knife-like" abdominal pain with vaginal bleeding Explanation: The classic manifestations of abruption placenta are painful dark red vaginal bleeding, "knife-like" abdominal pain, uterine tenderness, contractions, and decreased fetal movement. Painless bright red vaginal bleeding is the clinical manifestation of placenta previa. Generalized vasospasm is the clinical manifestation of preeclampsia and not of abruptio placenta.
A client reporting she recently had a positive pregnancy test has reported to the emergency department stating one-sided lower abdominal pain. The health care provider has prescribed a series of tests. Which test will provide the most definitive confirmation of an ectopic pregnancy? Quantitative human chorionic gonadotropin (hCG) test Qualitative human chorionic gonadotropin (hCG) test Pelvic examination Abdominal ultrasound
Abdominal ultrasound Explanation: An ectopic pregnancy refers to the implantation of the fertilized egg in a location other than the uterus. Potential sites include the cervix, uterus, abdomen, and fallopian tubes. The confirmation of the ectopic pregnancy can be made by an ultrasound, which would confirm that there was no uterine pregnancy. A quantitative hCG level may be completed in the diagnostic plan. hCG levels in an ectopic pregnancy are traditionally reduced. While this would be an indication, it would not provide a positive confirmation. The qualitative hCG test would provide evidence of a pregnancy, but not the location of the pregnancy. A pelvic exam would be included in the diagnostic plan of care. It would likely show an enlarged uterus and cause potential discomfort to the client but would not be a definitive finding.
There are four essential components of labor. The first is the passageway. It is composed of the bony pelvis and soft tissues. What is one component of the passageway? False pelvis Cervix Perineum Uterus
Cervix Explanation: The cervix and vagina are soft tissues that form the part of the passageway known as the birth canal.
Which primary symptom does the nurse identify as a potentially fatal complication of epidural or intrathecal anesthesia? Difficulty breathing Staggering gait Decreased level of consciousness Intense pain
Difficulty breathing Explanation: Total spinal blockade occurs when an inadvertent injection of a local anesthetic is placed into the intrathecal or epidural space. The resulting effect is that the anesthetic travels too high in the body causing paralysis of the respiratory muscles. Difficulty breathing is a sign. A decreased level of consciousness will occur later. A staggering gait or intense pain is not a primary symptom.
A 28-year-old client with a history of endometriosis presents to the emergency department with severe abdominal pain and nausea and vomiting. The client also reports her periods are irregular with the last one being 2 months ago. The nurse prepares to assess for which possible cause for this client's complaints? Healthy pregnancy Ectopic pregnancy Molar pregnancy Placenta previa
Ectopic pregnancy Explanation: The most commonly reported symptoms of ectopic pregnancy are pelvic pain and/or vaginal spotting. Other symptoms of early pregnancy, such as breast tenderness, nausea, and vomiting, may also be present. The diagnosis is not always immediately apparent because many women present with complaints of diffuse abdominal pain and minimal to no vaginal bleeding. Steps are taken to diagnose the disorder and rule out other causes of abdominal pain. Given the history of the client and the amount of pain, the possibility of ectopic pregnancy needs to be considered. A healthy pregnancy would not present with severe abdominal pain unless the client were term and she was in labor. With a molar pregnancy the woman typically presents between 8 to 16 weeks' gestation reporting painless (usually) brown to bright red vaginal bleeding. Placenta previa typically presents with painless, bright red bleeding that begins with no warning.
The nurse is admitting a client who is in early labor. After determining that the birth is not imminent, which assessment should the nurse perform next? Risk factors Maternal status Fetal status Maternal obstetrical history
Fetal status Explanation: The woman may present to the birthing suite at any phase of the first stage of labor. Therefore, it is important to assess birth imminence, fetal status, risk factors, and maternal status immediately. If birth is not imminent and the fetal and maternal conditions are stable, perform additional data collection, including the full admission health history, a complete maternal physical assessment, the status of labor and any labor, birth, and cultural preferences the woman may have.
The nurse is caring for a client in active labor. Which assessment finding requires health care provider notification? Gross proteinuria Hyperventilation Elevated WBC count Nausea
Gross proteinuria Explanation: There are normal physiologic changes that occur during the labor process. Gross proteinuria is not anticipated and is a sign of a complication. The health care provider is notified. If hyperventilation occurs, the woman is encouraged to breathe into her cupped hands or a paper bag. An elevated white blood cell count is common due to the immune response. Nausea is common due to prolonged gastric emptying.
The nurse is assisting a client through labor, monitoring her closely now that she has received an epidural. Which finding should the nurse prioritize to the anesthesiologist? Dry, cracked lips Urinary retention Rapid progress of labor Inability to push
Inability to push Explanation: If the client is not able to push, her epidural dose may need to be adjusted to decrease the impact on the sensory system. Dry lips indicate that she may need fluids, so the nurse should give her some ice chips or a drink of water. Urinary retention and rapidly progressing labor should be directly reported to the obstetrician, not the anesthesiologist.
A nursing instructor is conducting a class on the various types of pelvic shapes to a group of nursing students. The instructor determines the class is successful when the students correctly choose which factor is specific for an anthropoid pelvis? Is narrow transversely Is ideal for birth Has weaker bones than normal Is "male" shaped
Is narrow transversely Explanation: A gynecoid pelvis is the best shape for birth. An anthropoid pelvis is usually narrow. A "male" pelvis is termed an "android pelvis." The condition of the bones is not a determining factor for the shape of the pelvis.
The nurse is instructing on maternal hormones which may impact the onset of labor. Which hormones are included in the discussion? Select all that apply. Testosterone Oxytocin Thyroxine Progesterone Prostaglandins Insulin
Oxytocin Progesterone Prostaglandins Explanation: There are several hypotheses regarding what triggers labor to begin. Progesterone is the hormone of pregnancy and elimination may cause the uterus to contract. Oxytocin also causes the uterus to contract. Prostaglandins cause the cervix to soften and also cause the uterus to contract. Testosterone, thyroxine, and insulin are not one of the main factors in the onset of labor theories.
The nurse is instructing a group of women of childbearing age about human immunodeficiency virus (HIV) during pregnancy. What would be a priority recommendation in this setting? Screening for sexually transmitted infections (STIs) Screening for HIV Prophylactic treatment for HIV Proper nutrition
Screening for HIV Explanation: No screening mandate has been put forth for HIV, but all pregnant women should be encouraged to undergo this test. Prophylactic treatment would be initiated only once the woman has been screened. Screening for STIs and ensuring proper nutrition are also part of health promotion for women in this age group, but they are of lower priority than identifying HIV-positive individuals.
A nurse is auscultating the fetal heart rate of a woman in labor. To ensure that the nurse is assessing the FHR and not the mother's heart rate, which action would be most appropriate for the nurse to do? Palpate the mother's radial pulse at the same time. Ask the woman to hold her breath while assessing the FHR. Have the woman lie completely flat on her back while auscultating. Instruct the woman to bend her knees and flex her hips.
Palpate the mother's radial pulse at the same time. Explanation: To ensure that the maternal heart rate is not confused with the FHR, palpate the client's radial pulse simultaneously while the FHR is being auscultated through the abdomen. Having the woman hold her breath would be inappropriate and possibly dangerous. Lying flat or bending the knees and flexing the hips would have no effect on determining if the heart rate being assessed is of the fetus or the mother.
A woman with known cardiac disease is in labor. In what position would the nurse place the client? High-Fowler with a pillow at the back Supine Trendelenburg Semi-recumbent with a pillow under one hip
Semi-recumbent with a pillow under one hip Explanation: A laboring mother with known cardiac disease needs to be positioned in a semi-recumbent position and have a wedge or pillow placed under one hip. A cardiac client is never placed in a supine position because being flat on the back can lead to supine hypotensive syndrome, which leads to decreased placental perfusion and can increase the maternal cardiac output. Sitting straight up may be uncomfortable for the mother. Trendelenburg is definitely a wrong position due to the abdomen pressing against the diaphragm; it is also counter to the natural position of the uterus down toward the cervix.
Over the past 20 weeks, the following blood pressure readings are documented for a pregnant client with chronic hypertension: week 16 - 130/86 mm Hg; week 20 - 138/88 mm Hg; week 24 - 136/82 mm Hg; and week 28 - 138/88 mm Hg. The nurse interprets these findings as indicating which classification of her blood pressure? Elevated Stage 1 Stage 2 Hypertensive crisis
Stage 1 Explanation: Chronic hypertension exists when the woman has high blood pressure before pregnancy or before the 20th week of gestation, or when hypertension persists for more than 12 weeks. The Eighth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (Joint National Committee [JNC 8], 2018) blood pressure guidelines classify hypertension as follows: elevated: Systolic between 120 and 129 mm Hg and diastolic less than 80 mm Hg; Stage 1: Systolic between 130 and 139 mm Hg or diastolic between 80-89 mm Hg; Stage 2: Systolic at least 140 mm Hg or diastolic at least 90 mm Hg; Hypertensive crisis: Systolic over 180 mm Hg and/or diastolic over 120 mm Hg (Alexander, 2019; Bakris, 2019). The client has stage 1 hypertension.
A client experiencing contractions presents at a health care facility. Assessment conducted by the nurse reveals that the client has been experiencing Braxton Hicks contractions. The nurse has to educate the client on the usefulness of Braxton Hicks contractions. Which role do Braxton Hicks contractions play in aiding labor? These contractions help in softening and ripening the cervix. These contractions increase the release of prostaglandins. These contractions increase oxytocin sensitivity. These contractions make maternal breathing easier.
These contractions help in softening and ripening the cervix. Explanation: Braxton Hicks contractions assist in labor by ripening and softening the cervix and moving the cervix from a posterior position to an anterior position. Prostaglandin levels increase late in pregnancy secondary to elevated estrogen levels; this is not due to the occurrence of Braxton Hicks contractions. Braxton Hicks contractions do not help in bringing about oxytocin sensitivity. Occurrence of lightening, not Braxton Hicks contractions, makes maternal breathing easier.
A 17-year-old client comes to the clinic because of irregular menstrual bleeding and facial acne. The client is overweight, despite exercising daily, and has excessive hair growth on the chin and abdomen. The nurse explains to the client that blood will be drawn for which purposes? Select all that apply. To screen for insulin resistance To obtain fasting cholesterol levels To rule out polycystic ovary syndrome To screen for hypertension To measure androgen level
To screen for insulin resistance To obtain fasting cholesterol levels To measure androgen level Explanation: There is no single blood test to diagnose polycystic ovary syndrome (PCOS). However, a blood test to screen for insulin resistance, elevated androgen level, and elevated cholesterol level are used to identify clients with PCOS. There is no blood test to screen for hypertension.
A pregnant woman is admitted to the hospital with a diagnosis of placenta previa. Which action would be the priority for this woman on admission? performing a vaginal examination to assess the extent of bleeding helping the woman remain ambulatory to reduce bleeding assessing fetal heart tones by use of an external monitor assessing uterine contractions by an internal pressure gauge
assessing fetal heart tones by use of an external monitor Explanation: Not disrupting the placenta is a prime responsibility in caring for a patient with placenta previa, so an external fetal monitor would be used. An internal monitor, a vaginal examination, and remaining ambulatory could all disrupt the placenta and thus are contraindicated.
During a prenatal visit a pregnant client asks the nurse how to tell whether the contractions she is having are true contractions or Braxton Hicks contractions. Which description should the nurse mention as characteristic of true contractions? Select all that apply. begin irregularly but become regular and predictable felt first in lower back and sweep around to the abdomen in a wave increase in duration, frequency, and intensity begin and remain irregular felt first abdominally and remain confined to the abdomen and groin often disappear with ambulation or sleep
begin irregularly but become regular and predictable felt first in lower back and sweep around to the abdomen in a wave increase in duration, frequency, and intensity Explanation: True contractions begin irregularly but become regular and predictable; are felt first in the lower back and sweep around to the abdomen in a wave; continue no matter what the woman's level of activity; increase in duration, frequency, and intensity; and achieve cervical dilatation. False (Braxton Hicks) contractions begin and remain irregular; are felt first abdominally and remain confined to the abdomen and groin; often disappear with ambulation or sleep; do not increase in duration, frequency, or intensity; and do not achieve cervical dilatation.
A 29-year-old client has gestational diabetes. The nurse is teaching her about managing her glucose levels. Which therapy would be most appropriate for this client? diet long-acting insulin oral hypoglycemic drugs glucagon
diet Explanation: Clients with gestational diabetes are usually managed by diet alone to control their glucose intolerance. Long-acting insulin usually is not needed for blood glucose control in the client with gestational diabetes. Oral hypoglycemic drugs are contraindicated in pregnancy. Glucagon raises blood glucose and is used to treat hypoglycemic reactions.
The nurse is required to assess a client for HELLP syndrome. Which are the signs and symptoms of this condition? Select all that apply. blood pressure higher than 160/110 mm Hg epigastric pain oliguria upper right quadrant pain hyperbilirubinemia
epigastric pain upper right quadrant pain hyperbilirubinemia Explanation: The signs and symptoms of HELLP syndrome are nausea, malaise, epigastric pain, upper right quadrant pain, demonstrable edema, and hyperbilirubinemia. Blood pressure higher than 160/110 mm Hg and oliguria are the symptoms of severe preeclampsia rather than HELLP syndrome.
A client has been admitted with placental abruption. She has lost 1,200 mL of blood, is normotensive, and ultrasound indicates approximately 30% separation. The nurse documents this as which classification of abruptio placentae? grade 2 grade 1 grade 3 grade 4
grade 2 Explanation: The classifications for abruptio placentae are: grade 1 (mild) - minimal bleeding (less than 500 mL), 10% to 20% separation, tender uterus, no coagulopathy, signs of shock or fetal distress; grade 2 (moderate) - moderate bleeding (1,000 to 1,500 mL), 20% to 50% separation, continuous abdominal pain, mild shock, normal maternal blood pressure, maternal tachycardia; grade 3 (severe) - absent to moderate bleeding (more than 1,500 mL), more than 50% separation, profound shock, dark vaginal bleeding, agonizing abdominal pain, decreased blood pressure, significant tachycardia, and development of disseminated intravascular coagulopathy. There is no grade 4.
When educating a group of nursing students about the different types of pelvis, the nurse describes one type as being flat, having a wider transverse diameter than anterior-posterior diameter, with ischial spines that are wide apart, and a short sacrum. The students are correct when they identify this description with which type? gynecoid anthropoid platypelloid android
platypelloid Explanation: Platypelloid pelvis is a flat pelvis with a wider transverse diameter than anterior-posterior diameter, ischial spines are wide apart, and the sacrum is short. In a gynecoid pelvis, the inlet is oval, the pubic arch is wide, it has dull ischial spines, and the sacrum has no anterior or posterior inclinations. In an android pelvis, the inlet is heart shaped, the ischial spines are prominent, and the sacrum is straight. In an anthropoid pelvis, the anterior-posterior diameter is longer than the transverse diameter, ischial spine is somewhat prominent, and the sacrum is inclined posteriorly.
A 24-year-old client presents in labor. The nurse notes there is an order to administer Rho(D) immune globulin after the birth of her infant. When asked by the client the reason for this injection, which reason should the nurse point out? promote maternal D antibody formation. prevent maternal D antibody formation. stimulate maternal D immune antigens. prevent fetal Rh blood formation.
prevent maternal D antibody formation. Explanation: Because Rho(D) immune globulin contains passive antibodies, the solution will prevent the woman from forming long-lasting antibodies which may harm a future fetus. The administration of Rho(D) immune globulin does not promote the formation of maternal D antibodies; it does not stimulate maternal D immune antigens or prevent fetal Rh blood formation.
A pregnant client at 14 weeks' gestation calls the clinic. When talking with the nurse, the client reports continued, frequent nausea and vomiting. She states, "This has been happening since I got pregnant and now I cannot keep anything down." Which intervention would be the priority for this client? stopping all intake of food and drink initiating intravenous access for fluids administering an antiemetic obtaining serum electrolyte levels
stopping all intake of food and drink Explanation: Hyperemesis gravidarum is nausea and vomiting in early pregnancy that prevents the woman from ingesting adequate nutrition. IV fluids may be required for rehydration, but the priority is to stop all intake of food and fluid for a period of time until vomiting has stopped. Once this is done, IV access and fluids, antiemetics, and laboratory tests can be done.
A client in the third stage of labor has experienced placental separation and expulsion. Why is it necessary for a nurse to massage the woman's uterus briefly until it is firm? to reduce boggy nature of the uterus to remove pieces left attached to uterine wall to constrict the uterine blood vessels to lessen the chances of conducting an episiotomy
to constrict the uterine blood vessels Explanation: The nurse must massage the client's uterus briefly after placental expulsion to constrict the uterine blood vessels and minimize the possibility of hemorrhage. Massaging the client's uterus will not lessen the chances of conducting an episiotomy. In addition, an episiotomy, if required, is conducted in the second stage of labor not the third. The client's uterus may appear boggy only in the fourth stage of labor not in the third stage. Ensuring that all sections of the placenta are present and that no piece is left attached to the uterine wall is confirmed through a placental examination after expulsion.
A nurse is discussing the advantages and disadvantages of intermittent and continuous fetal heart rate monitoring with a colleague. What would the nurse cite as being able to be detected when using continuous monitoring but not intermittent monitoring? Select all that apply. types of decelerations variability FHR baseline changes in baseline rhythm
types of decelerations variability Explanation: Intermittent FHR auscultation can be used to detect FHR baseline and rhythm and changes from baseline. However, it cannot detect variability and types of decelerations like electronic fetal monitoring (EFM) can.
Which nursing interventions align with the outcome of preventing maternal and fetal injury in the latent phase of the first stage of labor? Select all that apply. Monitor maternal and fetal vital statistics every hour. Report an elevated temperature over 38℃ (100.4℉). Answer questions and encourage verbalization of fears. Have a client remain on bed rest with bathroom privileges only. Position client on the left side throughout the labor process.
vMonitor maternal and fetal vital statistics every hour. Report an elevated temperature over 38℃ (100.4℉). Answer questions and encourage verbalization of fears. Explanation: Consider what occurs in the latent (or early phase) of the first stage of labor, which are contractions and effacement. The nursing interventions that impact maternal and fetal injury include monitoring vital statistics, reporting temperature elevation over 38℃ (100.4℉), and answering questions and encouraging client verbalization of fears. The client is often excited and talkative. The client does not need to be on bed rest or positioned on the left side unless there is a complication.
A student observes during an initial prenatal visit. The student states, "I heard the primary care provider say that the client has a gynecoid pelvis. What does that mean?" The best response by the nurse is: "It is a typical male pelvis. With this type of pelvis, large neonates must be born by cesarean birth although some small neonates are able to be born vaginally." "It is flat and narrow, making it extremely difficult for the neonate to pass through." "It is rounded in shape and allows ample room for the neonate to fit through the passageway." "It is elongated, the width is roomy, but the length is narrow."
"It is rounded in shape and allows ample room for the neonate to fit through the passageway." Explanation: The gynecoid pelvis is most favorable for a vaginal birth. The rounded shape of the gynecoid pelvis inlet allows the fetus room to pass through the dimensions of the bony passageway.
A nurse is preparing a presentation for a group of new parents and is planning to discuss nutrition during the first year. As part of the presentation, the nurse is planning to address foods that should be avoided to reduce the risk of possible food allergies. Which foods would the nurse most likely include? Select all that apply. Eggs Shrimp Peanuts Carrots Potatoes Bananas
Eggs Shrimp Peanuts Explanation: Foods that should be avoided in children younger than 1 year of age include cow's milk, eggs, peanuts, tree nuts, sesame seeds, and fish and shellfish (i.e., shrimp). Carrots, potatoes, and bananas are not considered problematic.
If the monitor pattern of uteroplacental insufficiency were present, which action would the nurse do first? Help the woman to sit up in a semi-Fowler's position. Turn her or ask her to turn to her side. Administer oxygen at 3 to 4 L by nasal cannula. Ask her to pant with the next contraction.
Turn her or ask her to turn to her side. Explanation: The most common cause of uteroplacental insufficiency is compression of the vena cava; turning the woman to her side removes the compression.
A nurse is caring for a pregnant client who is in labor. Which maternal physiologic responses should the nurse monitor for in the client as the client progresses through birth? Select all that apply. increase in heart rate increase in blood pressure increase in respiratory rate slight decrease in body temperature increase in gastric emptying and pH
When caring for a client in labor, the nurse should monitor for an increase in the heart rate by 10 to 20 bpm, an increase in blood pressure by as much as 35 mm Hg, and an increase in respiratory rate. During labor, the nurse should monitor for a slight elevation in body temperature as a result of an increase in muscle activity. The nurse should also monitor for decreased gastric emptying and gastric pH, which increases the risk of vomiting with aspiration.
When providing discharge instructions to a child who was admitted to the hospital following stridor, wheezing, and urticaria after taking penicillin, which nursing action is priority? Question the child about the amount of penicillin that was taken. Encourage the child to wear a medical alert bracelet for penicillin. Advise the parents to have their child evaluated for atopic diseases. Educate the parents about possible side effects of penicillin in children.
When providing discharge instructions to a child who was admitted to the hospital following stridor, wheezing, and urticaria after taking penicillin, which nursing action is priority? Question the child about the amount of penicillin that was taken. Encourage the child to wear a medical alert bracelet for penicillin. Advise the parents to have their child evaluated for atopic diseases. Educate the parents about possible side effects of penicillin in children.
A pregnant client diagnosed with hyperemesis gravidarum is prescribed intravenous fluids for rehydration. When preparing to administer this therapy, which solution would the nurse anticipate being prescribed initially? normal saline dextrose 5% and water 0.45% sodium chloride albumin
normal saline Explanation: For the client with hyperemesis gravidarum, parenteral fluids and drugs are prescribed to rehydrate the client and reduce the symptoms. The first choice for fluid replacement is generally isotonic, such as normal saline, which aids in preventing hyponatremia, with vitamins (pyridoxine, or vitamin B6) and electrolytes added. Dextrose 5% and water and 0.45% sodium chloride are hypotonic solutions that would cause the cells to swell and possibly burst. Albumin could lead to fluid overload.
The five "Ps" of labor are: passageway, passenger, position, powers, psych. passenger, posture, position, presentation, psych. passenger, position, presentation, pushing, psych. passenger, position, powers, presentation, psych.
passageway, passenger, position, powers, psych. Explanation: The five "Ps" are passageway (birth canal), passenger (fetus and placenta), position (maternal), powers (contractions), and psych (maternal psychological response).