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A nurse is caring for a client at 39 weeks gestation

Exhibits
Click to highlight the findings below that would indicate that the client has a potential problem. To deselect a finding, click on the finding again.

Vital Signs

1130

Oral temperature 38.3 C (101 F )

Heart rate 98min

Respiratory rate 18/min

Blood pressure 112/59 mm Hg

Oxygen saturation 98% on room air

Nurses Notes

1130

Client states, ‘I think my water broke. The pad under me is soaked’. Clear fluid noted on pad. Nitrazine positive. Uterine contractions every 3 mins moderate to palpation. Fetal heart rate is 140/min.

Diagnostic Results

1200

HGB 10 g/dl (greater than 11 g/dl)

HCT 34% (greater that 33%)

WBC 22,000 ( 5,000 – 11,000)

Oral temperature 38.3 C (101 F )

HGB 10 g/dl (greater than 11 g/dl)

Heart rate 98min

Blood pressure 110/60 mm Hg

Uterine contractions every 3 mins moderate to palpation

Answer and Explanation

The Correct Answer is ["A","B"]

Oral temperature 38.3°C (101°F)
Elevated temperature indicates maternal fever, which could suggest infection such as chorioamnionitis, especially concerning with ruptured membranes.
HGB 10 g/dL (normal > 11 g/dL)
Low hemoglobin indicates anemia, which could compromise oxygen delivery to the fetus and affect maternal health during labor.

Explanation for non-highlighted findings:

Heart rate 98/min: Slightly elevated but within normal range for labor.
Blood pressure 112/59 mm Hg: Normal blood pressure for pregnancy.
Uterine contractions every 3 mins moderate to palpation: Normal pattern for active labor.

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Correct Answer is B

Explanation

A. A transvaginal fetal Doppler is not commonly used for continuous monitoring and is typically reserved for early pregnancy.
B. An external ultrasound transducer is appropriate for continuous fetal monitoring when the membranes are intact. It is noninvasive and safe for use during labor.
C. A DeLee Hillis fetoscope is used for intermittent auscultation, not continuous monitoring.
D. An internal fetal scalp electrode requires ruptured membranes and cervical dilation; it is contraindicated with intact membranes.

A. Instruct the parent to avoid eye contact with the newborn during feeding. B. Weigh the newborn daily. C. Plan to administer naloxone. D. Instruct the parent to avoid breastfeeding E. Maintain a low stimulation environment F. Swaddle the newborn with flexed extremities. G. Perform Ballard newborn screening each shift.

Correct Answer is ["B","E","F"]

Explanation

A. Instruct the parent to avoid eye contact with the newborn during feeding – This is not recommended. While overstimulation should be minimized, gentle eye contact and bonding are still encouraged during feeding to promote attachment.

B. Weigh the newborn daily – Weight loss and feeding difficulties are common in NAS. Daily weight monitoring is essential to evaluate nutritional status and fluid balance.

C. Plan to administer naloxone – Naloxone is contraindicated in opioid-exposed neonates because it can precipitate acute withdrawal and seizures.

D. Instruct the parent to avoid breastfeeding – Breastfeeding is generally encouraged unless the mother is using illicit substances or is HIV-positive. Methadone is not a contraindication for breastfeeding.

E. Maintain a low stimulation environment – NAS newborns are easily overstimulated. A quiet, dimly lit environment helps reduce symptoms like irritability and tremors.

F. Swaddle the newborn with flexed extremities – Swaddling provides comfort and containment, helping to reduce stress responses in NAS infants.

G. Perform Ballard newborn screening each shift – The Ballard score is used once to assess gestational age and is not repeated every shift.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a full term client in labor who is prescribed continuous fetal monitoring. On examination, the nurse determines the client's membranes are intact. Which of the following assessment methods should the nurse implement?

Correct Answer is B

Explanation

A nurse is caring for a newborn who is 5 days old. Exhibits Which of the following actions should the nurse take? Select all that apply.

Correct Answer is ["B","E","F"]

Explanation

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