Frequently Tested Questions With ELABORATED 100% Correct COMPLETE SOLUTIONS
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Amniotic fluid is stained with meconium is correct. This
A nurse is caring for a client who is in active labor and just
is an unexpected finding that requires further evaluation.
had an amniotomy performed by the provider. Which of
Meconium-stained amniotic fluid can indicate fetal dis-
the following findings indicates a need for further evalu-
tress.
ation?
Minimal FHR variability is correct. This is an unexpected
Select all that apply.
finding that requires further evaluation. Minimal or absent
variability can indicate fetal metabolic acidemia or hypox-
Amniotic fluid is stained with meconium
emia at the time it is observed.
Minimal FHR variability
An abrupt decrease in the FHR below the baseline is cor-
A change in the fetal station from 0 to +2
rect. This is an unexpected finding that requires further
An abrupt decrease in the FHR below the baseline
evaluation. This finding indicates a variable deceleration,
Stronger and more frequent uterine contractions
which is a manifestation of cord compression.
A nurse in the newborn nursery is caring for a newborn
Determine the newborn's age in hours.
who has jaundice. Which of the following actions should
the nurse take to determine if the jaundice is pathologic?
The nurse should first confirm the newborn's age in hours
Determine the newborn's age in hours.
to determine if the jaundice is pathologic or physiologic.
Perform a New Ballard Score assessment.
Jaundice that appears within the first 24 hr of birth is
Blanch the skin to assess for a yellow hue.
pathologic and jaundice that occurs after 24 hr is phys-
Request a prescription to obtain a blood specimen for a
iologic.
bilirubin level.
A nurse in a prenatal clinic is caring for a client who is Shortness of breath and wheezing at rest
at 24 weeks of gestation. Which of the following findings
requires immediate attention? Shortness of breath at rest along with other pulmonary
Abdominal bloating and constipation for 2 days symptoms such as cough, crackles, and wheezing are un-
Presence of a third heart sound upon auscultation expected. This finding requires immediate attention due
Shortness of breath and wheezing at rest to the client's and fetus's risk for hypoxia associated with
Client report of increased, odorless vaginal discharge impaired maternal airways.
"I felt my baby move six times in the past 2 hours" is
correct. This finding indicates a need for further evalua-
tion. Expected fetal movement is at least 10 movements
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Frequently Tested Questions With ELABORATED 100% Correct COMPLETE SOLUTIONS
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within a 2-hr period. A prompt evaluation is needed if fetal
A nurse is caring for a client who is at 32 weeks of gesta-
movement is less than 10 movements within 2 hr.
tion during a routine prenatal visit. Which of the following
"I feel unusually weak and fatigued since we returned
client statements indicates a need for further evaluation?
from our cruise last week" is correct. Although fatigue
Select all that apply.
is expected during pregnancy, this statement indicates a
need for further evaluation because traveling outside the
"I felt my baby move six times in the past 2 hours."
country increases this client's risk of exposure to infec-
"I notice my feet are a little swollen at the end of the day."
tions.
"I have been having lower back pain lately, especially after
"I have this pain under my right rib, especially after eat-
prolonged standing."
ing" is correct. Right upper quadrant pain, especially after
"I feel unusually weak and fatigued since we returned
ingestion of high-fat foods, can indicate cholelithiasis. This
from our cruise last week."
is an unexpected finding that indicates a need for further
"I have this pain
evaluation.
Breast enlargement and tenderness is correct. In the first
trimester of pregnancy, the breast enlarges, becomes ten-
A client presents for initial prenatal care at 10 weeks der, and the areola darkens due to increased melanocyte
of gestation. Which of the following findings should the production caused by pregnancy hormones.
nurse expect? Resting heart rate increase by 10 to 30/min is correct.
Select all that apply. Beginning in early pregnancy, the resting heart rate in-
creases by 10 to 30/ min due to increased cardiac output.
Breast enlargement and tenderness Mild dyspnea while walking is correct. Mild dyspnea dur-
Mild dyspnea while walking ing exertion and deep respirations beginning in the first
Nausea, especially in the morning or second trimester are expected due to rising levels of
Burning when voiding progesterone.
Resting heart rate increase by 10 to 30/min Nausea, especially in the morning is correct. Nausea with
or without vomiting, or "morning sickness," is expected in
early pregnancy due to hormonal changes.
A nurse is caring for a client who has voided 70 mL of urine Palpate for bladder distention.
since giving birth 6 hr ago. Which of the following actions
should the nurse take? Voiding a small volume of urine is a finding associated
Palpate for bladder distention. with urinary retention. The nurse should palpate the blad-
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