A nurse is caring for a 26-year-old female client in the labor and delivery unit. The client is gravida 2, para 1, term 1, living 1, and is admitted with cervical dilation of 4 cm, 70% effacement, and -1 station. The pregnancy has been uncomplicated.

Exhibits:

Exhibits

The nurse reviews the client data. Drag the word choices to complete the sentence.
Abnormal FHR patterns can result in
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,
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, and
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.

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C","dropdown-group-3":"E"}

Acidemia: Acidemia refers to an abnormal acidity in the blood (pH < 7.35). Prolonged abnormal FHR patterns can indicate insufficient oxygen delivery to the fetus, leading to anaerobic metabolism and the production of lactic acid, causing acidemia. The normal fetal pH is around 7.30-7.35.

Hypoxemia: Hypoxemia is a reduced level of oxygen in the blood. Abnormal FHR patterns may signal that the fetus is not receiving adequate oxygen, potentially due to cord compression, placental insufficiency, or other factors affecting oxygen transfer. Normal oxygen saturation for a fetus is generally around 30-70%.

Hypoxia: Hypoxia is a condition where there is insufficient oxygen available to meet the metabolic needs of the fetus. Abnormal FHR patterns can indicate ongoing or impending hypoxia, which can lead to severe fetal distress and compromise. It is crucial to monitor and address such conditions promptly.

Rationale for Incorrect Answers:

Hypoglycemia: Hypoglycemia refers to low blood glucose levels (typically < 45 mg/dL in newborns). Abnormal FHR patterns are not directly associated with changes in glucose metabolism. Rather, hypoglycemia in neonates is often related to maternal diabetes, prematurity, or other metabolic disturbances.

Meconium Stool: Meconium-stained amniotic fluid is a possible indicator of fetal distress but is not a direct result of abnormal FHR patterns. Meconium passage may be associated with post-term pregnancy, fetal hypoxia, or other factors, but the direct consequences of abnormal FHR patterns are more specifically related to oxygenation and acid-base status.

Maternal Hypotension: Maternal hypotension, or low blood pressure (typically < 90/60 mm Hg), is a maternal condition that can affect fetal well-being if severe and prolonged. However, it is not a direct result of abnormal FHR patterns. Instead, maternal hypotension can contribute to abnormal FHR by impairing uteroplacental perfusion.

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Correct Answer is ["A","C","D","E"]

Explanation

The correct answer is Choice A, Choice C, Choice D, Choice E.

Choice A rationale

Genetic counseling is recommended for couples concerned about birth defects to identify any potential genetic abnormalities or risks for inherited conditions.

Choice B rationale

Couples excited about having children do not necessarily require genetic counseling unless there are known risk factors or concerns about genetic conditions.

Choice C rationale

Loss of an embryo following an in-vitro fertilization procedure may indicate underlying genetic issues, warranting further evaluation through genetic counseling.

Choice D rationale

Huntington’s disease is an autosomal dominant disorder; individuals with a family history should seek genetic counseling to assess their risk of inheritance and possible transmission.

Choice E rationale

In-vitro fertilization with donated sperm may involve genetic screening and counseling to ensure the donor's genetic profile is compatible and free of heritable conditions.

A. Observe for signs of respiratory distress and monitor oxygenation by pulse oximetry. B. Keep infant in warmer with bilirubin lights to maintain temperature of 97.6° F (36.4° C). C. Monitor temperature. D. Continue to monitor glucose levels. E. Explain to the mother that the baby’s respiratory rate needs to be below 60 breaths/minute to be able to breastfeed. F. Tell the mother that she will need to discuss any concerns with the neonatologist. G. Inform the mother that the baby is stable enough to take out of the warmer and bilirubin lights.

Correct Answer is ["A","B","C","D"]

Explanation

Choice A rationale

Monitoring for respiratory distress and checking oxygenation by pulse oximetry are critical in newborns, as they can indicate hypoxemia or respiratory issues requiring prompt intervention.

Choice B rationale

Maintaining the infant's temperature at 97.6°F (36.4°C) using a warmer and bilirubin lights is essential for thermoregulation and treating jaundice, ensuring proper physiological stability.

Choice C rationale

Regular temperature monitoring is vital to detect any signs of hypothermia or hyperthermia, which can indicate underlying health issues and guide appropriate interventions for the newborn.

Choice D rationale

Continued monitoring of glucose levels is crucial for detecting hypoglycemia, a common condition in newborns that can lead to seizures, brain damage, or other severe complications if left untreated.

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Naxlex Comprehensive Predictor Exams

A nurse is conducting a preconception class for a group of parents who are anticipating having children. Which client(s) should the nurse refer for genetic counseling? (Select all that apply)

Correct Answer is ["A","C","D","E"]

Explanation

The nurse is reviewing laboratory results and nurse’s notes to determine which actions to take at this time. Which actions are appropriate for the nurse to take at this time? (Select all that apply)

Correct Answer is ["A","B","C","D"]

Explanation

The nurse is preparing to administer phytonadione to a newborn. Which statement made by the parents indicates understanding why the nurse is administering this medication?

At 0600, while admitting a woman for a scheduled repeat cesarean section (C-section), the client tells the nurse that she drank a cup of coffee at 0400 because she wanted to avoid getting a headache. Which action should the nurse take first?

A new parent asks the nurse about an area of swelling on the baby’s head near the posterior fontanel that lies across the suture line. How should the nurse respond?

A client whose labor is being augmented with an oxytocin infusion requests an epidural for pain control. Findings of the last vaginal exam, performed 1 hour ago, were 3 cm cervical dilation, 60% effacement, and a -2 station. Which action should the nurse implement first?

What instructions should the nurse provide to a new mother regarding postpartum care and monitoring the newborn’s health?