The laboring client's fetal heart rate baseline is 120 beats per minute (bpm). Accelerations are present to 135 bpm. During contractions, the fetal heart rate gradually slows to 110, and is at 120 by the end of the contraction.
What nursing action is best? 1. Document the fetal heart rate.
2. Apply oxygen via mask at 10 liters.
3. Prepare for imminent delivery.
4. Assist the client into Fowler's position.
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The nurse is providing care to the client during the second stage of labor. Which nursing action is appropriate?
A) Assessing fetal heart rate every 15 minutes in low risk clients
B) Administering antibiotics for a positive group beta strep
C) Assessing maternal temperature every 2-4 hours after amniotic membranes have ruptured
D) Encouraging the client to void because a full bladder can interfere with fetal descent
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A client in the fourth stage of labor is crying out in pain. Which of the following nursing diagnoses would be the most appropriate for the client at this time?
1. Fear
2. Anxiety
3. Acute Pain
4. Health-Seeking Behaviors
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The nurse is instructing a pregnant adolescent client on how the baby's condition is evaluated during labor. Which client statement indicates appropriate understanding of the information presented?
A) "During labor, the nurse will assess the baby's heart rate with an electronic fetal monitor."
B) "During labor, the nurse will look at the color and amount of bloody show that I have."
C) "During labor, the nurse will verify that my contractions are strong but not too close together."
D) "During labor, the nurse will check my cervix by doing a pelvic exam every two hours."
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The nurse is instructing a pregnant adolescent client on how the baby's condition is evaluated during labor. The nurse knows the client education was successful when the client states, During labor, the nurse will:
1. Check my cervix by doing a pelvic exam every two hours..
2. Assess the baby's heart rate with an electronic fetal monitor..
3. Look at the color and amount of bloody show that I have..
4. Verify that my contractions are strong but not too close together..
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The nulliparous states, "I have been in labor for 4 hours and I am still only 2 cm dilated. Why is this happening? I feel like I should be ready to push by now." Which is the best response by the nurse?
A) "The hormones that cause labor to begin are just getting to the levels that will change your cervix."
B) "What did you expect? You've only had contractions for a few hours. Labor takes time."
C) "Your cervix has also effaced, or thinned out, and that change in the cervix is also labor progress."
D) "When your perineal body thins out, your cervix will begin to dilate much faster than it is now."
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The nurse is conducting an initial prenatal assessment for a pregnant client. Which screenings should the nurse prepare the client for during this visit? (Select all that apply.)
1. Complete blood count (CBC)
2. Glucose tolerance test (GTT)
3. ABO and Rh typing
4. HIV screening
5. Urinalysis
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Jennie Smith is a 15-year-old female client who is a gravida 1, para 0 at 36 weeks gestation by both estimate date of birth and ultrasound. She began prenatal care at 10 weeks gestation and has had an uneventful pregnancy except for mild pedal edema that developed 1 week ago. Her 17-year-old boyfriend has been involved throughout the pregnancy.
Hi, I need help with this case study - Case Study: Preeclampsia. Please and thank you!
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A young adult client is at 28 weeks' gestation. The prenatal history reveals past drug abuse, and urine screening indicates that she has recently used heroin. Which potential fetal health problem should the nurse use to select a nursing diagnosis to guide care?
A) Abruptio placentae
B) Diabetes mellitus
C) Intrauterine growth restriction (IUGR)
D) Congenital anomalies
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After teaching a pregnant client about the effects of smoking on pregnancy, the nurse knows that the client needs further education when she states, "I am at increased risk for:
A) Pre-eclampsia."
B) Abruptio placentae."
C) Preterm birth."
D) Placenta previa."
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