N3610 Quiz 1 | Questions, Answers and Rationales A nurse is admitting a client who is at 38 weeks of gestation and is in the first stage of labor. Which of the following assessment findings should the nurse report to the provider first? A. Expulsion of a blood-tinged mucous plug B. Continuous con...
A nurse is admitting a client who is at 38 weeks of gestation and is in the first stage of
labor. Which of the following assessment findings should the nurse report to the
provider first?
A. Expulsion of a blood-tinged mucous plug
B. Continuous contraction lasting 2 min
C. Pressure on the perineum causing the client to bear down
D. Expulsion of clear fluid from the vagina
Rationale: A uterus contracting for more than 90 seconds is a sign of tetany and could
lead to uterine rupture, which is the greatest risk to the client at this time. The nurse
should report this finding immediately.
A nurse is providing teaching about nutrition to a client at her first prenatal visit. Which
of the following statements by the nurse should be included in the teaching?
A. "You will need to increase your calcium intake during breastfeeding."
B. "Prenatal vitamins will meet your need for increased vitamin D during pregnancy."
C. "Vitamin E requirements decline during pregnancy due to the increase in body fat."
D. "You will need to double your intake of iron during pregnancy."
Rationale: During pregnancy, the need for iron increases to allow transfer of the
appropriate amounts to the fetus and to support expansion of the client's red blood cell
volume.
A nurse is teaching about fetal development to a group of clients in the antenatal clinic.
Which of the following statements should the nurse include in the teaching?
A. "The baby's heart beat is audible by a Doppler stethoscope at 12 weeks of
pregnancy."
B. "The sex of the baby is determined by week 8 of pregnancy."
C. "Very fine hairs, called lanugo, cover your baby's entire body by week 36 of
pregnancy."
D. "You will first feel your baby move in week 24 of pregnancy."
Rationale: The fetal heartbeat is audible by Doppler stethoscope between 8 to 17 weeks
of gestation.
A nurse on the labor and delivery unit is caring for a client following a vaginal
examination by the provider which is documented as: -1. Which of the following
,interpretations of this finding should the nurse make?
A. The presenting part is 1cm above the ischial spines.
B. The presenting art is 1cm below the ischial spines.
C. The cervix is 1cm dilated.
D. The cervix is effaced 1cm.
Rationale: Station is the relation of the presenting part to the ischial spines of the
maternal pelvis and is measured in centimeters above, below, or at the level of the
spines. If the station is minus 1, then the presenting part is 1cm above the ischial
spines.
A nurse in a provider's office is caring for a client who is at 36 weeks of gestation and
scheduled for an amniocentesis. The client asks why she is having an ultrasound prior
to the procedure. Which of the following is an appropriate response by the nurse?
A. "This will determine is there is more than one fetus."
B. "It is useful for estimating fetal age."
C. "It assists in identifying the location of the placenta and fetus."
D. "This is a screening tool for spina bifida."
Rationale: Identifying the positions of the fetus, placenta, and amniotic fluid pockets
immediately prior to the amniocentesis increases the safety of this test by assisting with
correct placement of the needle.
A nurse on a labor unit is admitting a client who reports painful contractions. The nurse
determines that the contractions have a durtiong of 1min and a frequency of 3min. The
nurse obtains the following vitals: fetal heart rate 130/min, maternal heart rate 128/min,
and maternal blood pressure 92/54mmHg. Which of the following is the priority action
for the nurse to take?
A. Notify the provider of the findings.
B. Position the client with one hip elevated.
C. Ask the client if she needs pain medication.
D. Have the client void.
Rationale: Based on Maslow's hierarchy of needs, the client's need for an adequate
blood pressure to perfuse herself and her fetus is a physiological need that requires
immediate intervention. Supine hypotension is a frequent cause of low blood pressure in
clients who are pregnant. By turning the client on her side and retaking her blood
pressure, the nurse is attempting to correct the low blood pressure and reassess.
A nurse is caring for a group of clients on an intrapartum unit. Which of the following
findings should be reported to the provider immediately?
, A. A tearful client who is at 32 weeks of gestation and is experiencing irregular, frequent
contractions.
B. A client who is at 28 weeks of gestation and receiving terbutaline reports fine
tremors.
C. A client who has a diagnosis of preeclampsia has 2+ proteinuria and 2+ patellar
reflexes.
D. A client who has a diagnosis of preeclampsia reports epigastric pain and unresolved
headache.
Rationale: These findings indicate that the client's condition is worsening and are signs
of severe preeclampsia. They should be reported to the provider immediately. Other
manifestations of severe preeclampsia include: blood pressure of 160/100 mm Hg or
greater, proteinuria 3+ to 4+, oliguria, visual disturbances, such as blurred vision,
hyperreflexia with clonus, nausea, vomiting, epigastric pain, and right upper-quadrant
pain.
A nurse is caring for a client who is at 40 weeks gestation and is in active labor. The
client has 6cm of cervical dilation and 100% cervical effacement. The nurse obtains the
client's blood pressure reading as 82/52mmHg. Which of the following nursing
interventions should the nurse perform?
A. Prepare for a cesarean birth.
B. Assist the client to an upright position.
C. Prepare for an immediate vaginal delivery.
D. Assist the client to turn onto her side.
Rationale: Maternal hypotension results from the pressure of the enlarged uterus on the
inferior vena cava. Turning the client to her right side relieves this pressure and restores
blood pressure to the expected reference range.
A nurse is caring for a client who is having a nonstress test performed. The fetal heart
rate is 130 to 150/min, but there has been no fetal movement for 15min. Which of the
following actions should the nurse perform?
A. Immediately report the situation to the client's provider and prepare the client for
induction of labor.
B. Encourage the client to walk around without the monitoring unit for 10min, then
resume monitoring.
C. Offer the client a snack of orange juice and crackers.
D. Turn the client onto her left side.
Rationale: A nonstress test depends upon fetal movement, and this fetus is most likely
asleep. Most fetuses are more active after meals due to the increase in the mother's
blood sugar. Giving the mother a snack will promote fetal movement.
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