Question

A nurse is observing the electronic fetal heart rate monitor tracing for a client who is at 40 weeks of gestation and is in labor. The nurse should suspect a problem with the umbilical cord when she observes which of the following patterns?

Answer 1

Correct Answers:

variable decelerations

Rationale :

🧵 Variable decelerations are characterized by sudden, abrupt decreases in fetal heart rate (FHR) that vary in duration, depth, and timing relative to uterine contractions.

🧵 They are typically V-shaped or U-shaped on the monitor and are not consistently aligned with contractions.

🧵 These decelerations are most commonly caused by umbilical cord compression, which reduces blood flow and oxygen to the fetus intermittently.

🧵 Causes may include nuchal cord (cord around the neck), oligohydramnios, or cord prolapse.

🧵 Management may include maternal repositioning, oxygen administration, amnioinfusion, or emergency intervention if the pattern worsens or persists.

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Answer 2

Correct Answers:

Saturated perineal pad in 30 min

Rationale :

🩸 A saturated perineal pad in 30 minutes indicates excessive vaginal bleeding, suggesting postpartum hemorrhage, which is a life-threatening emergency.

🩸 Hemorrhage is the leading cause of maternal morbidity in the immediate postpartum period and requires prompt evaluation and intervention.

🩸 The nurse should immediately assess fundal firmness, massage if boggy, and notify the provider.

🩸 Other findings (e.g., fundus location, DTRs) are important but not emergent.

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Answer 3

Correct Answers:

Ask the client if she has considered harming her newborn.

Rationale :

🧠 At 3 weeks postpartum, the client’s description of feeling "down," sad, having no energy, and wanting to cry exceeds typical “baby blues” and aligns with postpartum depression (PPD).

🧠 The priority for the nurse is to assess for signs of postpartum psychosis or suicidal/infanticidal ideation, both of which are psychiatric emergencies.

🧠 Direct questioning such as "Have you thought about harming yourself or the baby?" is clinically appropriate, therapeutic, and ensures immediate safety.

🧠 Delaying this question or assuming a mild emotional state may result in missed diagnosis and potential harm to the client or infant.

🧠 Only after ruling out harm risk should the nurse consider additional steps like psychiatric referral, antidepressants, or support planning.

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Answer 4

Correct Answers:

Dry the skin.

Rationale :

🧴 Immediately after establishing a patent airway, thermoregulation becomes the next essential task in newborn transitional care.

🧴 Drying the skin prevents evaporative heat loss, which is the most common form of heat loss in newborns.

🧴 If a newborn gets cold, it increases oxygen and glucose demand, leading to hypoglycemia, hypoxia, respiratory distress, or acidosis.

🧴 While vitamin K, eye ointment, and identification are important, they are secondary to establishing a stable thermal environment.

🧴 Prompt drying with a warm towel and placing the infant skin-to-skin or under a warmer supports a smooth extrauterine transition.

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Answer 5

Correct Answers:

An excessive amount of amniotic fluid is present.

Rationale :

🌊 Polyhydramnios is defined as an amniotic fluid index (AFI) >24 cm or a single deepest pocket >8 cm, indicating excess fluid around the fetus.

🌊 It can result from maternal diabetes, fetal anomalies (such as esophageal atresia or anencephaly), or multiple gestation.

🌊 Excessive fluid can lead to uterine overdistention, increasing the risk for preterm labor, cord prolapse, malpresentation, and postpartum hemorrhage.

🌊 The fluid excess may prevent the fetus from engaging properly in the pelvis, contributing to labor complications.

🌊 Understanding this condition allows the nurse to monitor for uterine tone, fetal presentation, and the need for early interventions.

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Answer 6

Correct Answers:

Changes in the cervix

Rationale :

📏 The definitive sign that a client is in true labor is progressive cervical change—specifically, dilation and effacement.

📏 This distinguishes true labor from false labor (Braxton Hicks), which may cause discomfort but does not alter the cervix.

📏 The cervix becomes shorter (effaced) and opens (dilated) due to coordinated uterine contractions.

📏 Changes are assessed via vaginal exam by the nurse or provider to determine labor progression and readiness for admission.

📏 Rupture of membranes and fetal station can accompany labor but do not independently confirm it.

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Answer 7

Correct Answers:

Monitor blood glucose levels.

Rationale :

🧬 Newborns classified as small for gestational age (SGA) are at risk for hypoglycemia due to decreased glycogen stores, reduced subcutaneous fat, and increased metabolic demands.

🧬 Hypoglycemia in neonates can present with jitteriness, poor feeding, apnea, lethargy, or even seizures.

🧬 Prompt and regular glucose monitoring is essential, especially in the first 24 hours, when the risk is highest.

🧬 If low glucose levels are found, early feeding or IV dextrose must be initiated to prevent neurologic damage.

🧬 While monitoring temperature, weight, and I&Os is important, blood glucose is the most urgent parameter for this population.

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Answer 8

Correct Answers:

Discontinue the medication infusion.

Rationale :

🧯 The client's respiratory rate of 10 breaths/min and absent deep tendon reflexes are classic signs of magnesium sulfate toxicity.

🧯 Magnesium sulfate is used to prevent seizures in preeclampsia, but toxic levels depress the central nervous system and respiratory drive.

🧯 The first and immediate action is to stop the infusion, preventing further magnesium accumulation and progression to respiratory or cardiac arrest.

🧯 The nurse should then notify the provider, monitor for other signs (like bradycardia), and prepare to administer calcium gluconate, the antidote.

🧯 Blood glucose is unrelated, and positioning or cesarean delivery are inappropriate initial responses.

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Answer 9

Correct Answers:

Evaluate the firmness of the uterus.

Rationale :

🩸 A blood pressure of 60/50 mm Hg in a postpartum client suggests hypovolemic shock, most commonly due to postpartum hemorrhage.

🩸 The leading cause of postpartum hemorrhage is uterine atony—a soft, boggy uterus failing to contract and clamp down on blood vessels.

🩸 The first nursing action is to assess fundal tone. If the uterus is boggy, firm massage should be performed immediately to stimulate contraction.

🩸 Administering oxytocin and oxygen are appropriate, but only after identifying and confirming the source of bleeding.

🩸 Type and crossmatch is critical if transfusion is needed but is not the first step.

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Answer 10

Correct Answers:

A client who is at 28 weeks of gestation and reports of painless vaginal bleeding

Rationale :

🩸 Painless vaginal bleeding at 28 weeks of gestation is highly suggestive of placenta previa, a serious obstetric complication where the placenta partially or completely covers the cervical os.

🩸 This condition poses a significant risk for maternal hemorrhage and fetal compromise, and any bleeding in the second or third trimester warrants immediate evaluation with ultrasound and fetal monitoring.

🩸 The priority is to assess maternal hemodynamic stability (e.g., blood pressure, heart rate) and fetal well-being while avoiding vaginal examination, which could worsen the bleeding.

🩸 Other options (spotting in early pregnancy, nausea/vomiting at 14 weeks, or a cough and fever at 38 weeks) are important but do not pose the same immediate risk of hemorrhagic shock or fetal death as potential placenta previa.

🩸 Early identification and stabilization are essential to prevent preterm labor or emergency cesarean delivery due to uncontrolled bleeding.

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QLexNursing

1 :
A nurse is observing the electronic fetal heart rate monitor tracing for a client who is at 40 weeks of gestation and is in labor. The nurse should suspect a problem with the umbilical cord when she observes which of the following patterns?

2 :
A nurse is assessing a client who is 4 hr postpartum following a vaginal delivery. Which of the following findings should the nurse identify as the priority?

3 :
A nurse in a clinic is caring for a client who is 3 weeks postpartum following the birth of a healthy newborn. The client reports feeling "down" and sad, having no energy, and wanting to cry. Which of the following is a priority action by the nurse?

4 :
A nurse is caring for a newborn immediately following birth. After assuring a patent airway, what is the priority nursing action?

5 :
A nurse is caring for a client who was admitted to the maternity unit at 38 weeks of gestation and who is experiencing polyhydramnios. The nurse should understand that this diagnosis means which of the following?

6 :
A nurse is caring for a client who is a primigravida, at term, and having contractions but is stating that she is "not really sure if she is in labor or not." Which of the following should the nurse recognize as a sign of true labor?

7 :
A nurse is planning care for a newborn who is small for gestational age (SGA). Which of the following is the priority intervention the nurse should include in the newborn's plan of care?

8 :
A nurse is caring for a client who has preeclampsia and is being treated with magnesium sulfate IV. The client's respiratory rate is 101min and deep-tendon reflexes are absent. Which of the following actions should the nurse take?

9 :
A nurse is caring for a client who gave birth 2 hr ago. The nurse notes that the client's blood pressure is 60/50 mm Hg. Which of the following actions should the nurse take first?

10 :
A nurse in an antepartum unit is triaging clients. Which of the following clients should the nurse see first?

QLexNursing

1 : A nurse is observing the electronic fetal heart rate monitor tracing for a client who is at 40 weeks of gestation and is in labor. The nurse should suspect a problem with the umbilical cord when she observes which of the following patterns?

2 : A nurse is assessing a client who is 4 hr postpartum following a vaginal delivery. Which of the following findings should the nurse identify as the priority?

3 : A nurse in a clinic is caring for a client who is 3 weeks postpartum following the birth of a healthy newborn. The client reports feeling "down" and sad, having no energy, and wanting to cry. Which of the following is a priority action by the nurse?

4 : A nurse is caring for a newborn immediately following birth. After assuring a patent airway, what is the priority nursing action?

5 : A nurse is caring for a client who was admitted to the maternity unit at 38 weeks of gestation and who is experiencing polyhydramnios. The nurse should understand that this diagnosis means which of the following?

6 : A nurse is caring for a client who is a primigravida, at term, and having contractions but is stating that she is "not really sure if she is in labor or not." Which of the following should the nurse recognize as a sign of true labor?

7 : A nurse is planning care for a newborn who is small for gestational age (SGA). Which of the following is the priority intervention the nurse should include in the newborn's plan of care?

8 : A nurse is caring for a client who has preeclampsia and is being treated with magnesium sulfate IV. The client's respiratory rate is 101min and deep-tendon reflexes are absent. Which of the following actions should the nurse take?

9 : A nurse is caring for a client who gave birth 2 hr ago. The nurse notes that the client's blood pressure is 60/50 mm Hg. Which of the following actions should the nurse take first?

10 : A nurse in an antepartum unit is triaging clients. Which of the following clients should the nurse see first?

1 :
A nurse is observing the electronic fetal heart rate monitor tracing for a client who is at 40 weeks of gestation and is in labor. The nurse should suspect a problem with the umbilical cord when she observes which of the following patterns?

2 :
A nurse is assessing a client who is 4 hr postpartum following a vaginal delivery. Which of the following findings should the nurse identify as the priority?

3 :
A nurse in a clinic is caring for a client who is 3 weeks postpartum following the birth of a healthy newborn. The client reports feeling "down" and sad, having no energy, and wanting to cry. Which of the following is a priority action by the nurse?

4 :
A nurse is caring for a newborn immediately following birth. After assuring a patent airway, what is the priority nursing action?

5 :
A nurse is caring for a client who was admitted to the maternity unit at 38 weeks of gestation and who is experiencing polyhydramnios. The nurse should understand that this diagnosis means which of the following?

6 :
A nurse is caring for a client who is a primigravida, at term, and having contractions but is stating that she is "not really sure if she is in labor or not." Which of the following should the nurse recognize as a sign of true labor?

7 :
A nurse is planning care for a newborn who is small for gestational age (SGA). Which of the following is the priority intervention the nurse should include in the newborn's plan of care?

8 :
A nurse is caring for a client who has preeclampsia and is being treated with magnesium sulfate IV. The client's respiratory rate is 101min and deep-tendon reflexes are absent. Which of the following actions should the nurse take?

9 :
A nurse is caring for a client who gave birth 2 hr ago. The nurse notes that the client's blood pressure is 60/50 mm Hg. Which of the following actions should the nurse take first?

10 :
A nurse in an antepartum unit is triaging clients. Which of the following clients should the nurse see first?