A nurse is reviewing laboratory results of a pregnant patient.Which result will require further assessment?

Rubella titer 1:33.

Serologic test for syphilis (STS) - non-reactive.

Blood type A-negative.

Hemoglobin 12.2 gm/dL.

Answer and Explanation

The Correct Answer is A

A rubella titer of 1:33 indicates a low level of immunity to rubella, which can be dangerous for a pregnant woman and her fetus.

Rubella is a viral infection that can cause birth defects or miscarriage if contracted during pregnancy. A rubella titer of 1:10 or higher is considered protective.

Choice B is wrong because a non-reactive serologic test for syphilis (STS) means that the patient does not have syphilis, which is a bacterial infection that can also harm the fetus if untreated.

Choice C is wrong because blood type A-negative does not require further assessment unless the patient has antibodies to the Rh factor, which can cause hemolytic disease of the newborn if the fetus is Rh-positive.

This can be prevented by giving the patient Rh immunoglobulin injections during pregnancy and after delivery.

Choice D is wrong because hemoglobin 12.2 gm/dL is within the normal range for a pregnant woman, which is 11 to 14 gm/dL.

Hemoglobin is the protein in red blood cells that carries oxygen.

A low hemoglobin level can indicate anemia, which can affect the oxygen delivery to the fetus and increase the risk of preterm labor or low birth weight.

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Correct Answer is A

Explanation

The correct answer is choice A and it indicates fetal distress because it is a sign oflate deceleration.Late decelerations are due touteroplacental insufficiencyas the result of decreased blood flow and oxygen to the fetus during the uterine contractions.This causeshypoxemiaand can lead to fetal acidosis and neurological damage.

Choice B is wrong because it indicates anormal variabilityin the fetal heart rate, which reflects a healthy autonomic nervous system.A normal fetal heart rate is 120-160 beats per minute.

Choice C is wrong because it indicates anearly accelerationin the fetal heart rate, which is a benign finding that may occur with fetal movement or stimulation.

Choice D is wrong because it indicates anearly decelerationin the fetal heart rate, which is a normal response to fetal head compression during contractions.

It does not indicate fetal distress.

Normal ranges for fetal heart rate patterns are:

• Baseline: 120-160 beats per minute

• Variability: 6-25 beats per minute

• Accelerations: at least 15 beats per minute above baseline for at least 15 seconds

• Decelerations: none or early (mirror contractions)

A. Observe the patient for vaginal discharge of bright red blood. B. Assess the patient’s vaginal tone. C. Massage the patient’s perineum. D. Apply petrolatum to the patient’s perineum.

Correct Answer is D

Explanation

The correct answer is choice D. Apply petrolatum to the patient’s perineum.This is because petrolatum can help soothe and protect the perineal area, which may be swollen, bruised, or have stitches after a vaginal delivery.Applying petrolatum can also prevent the pad from sticking to the wound and causing more pain.

Choice A is wrong because observing the patient for vaginal discharge of bright red blood is not a specific action for perineal care.Bright red blood may indicate postpartum hemorrhage, which requires immediate medical attention.

Choice B is wrong because assessing the patient’s vaginal tone is not a priority action for perineal care.Vaginal tone may be reduced after childbirth due to stretching of the pelvic floor muscles, but this can improve with time and exercises.

Choice C is wrong because massaging the patient’s perineum is not recommended for perineal care.Massaging the perineum may cause more trauma and discomfort to the area, especially if there are stitches or hemorrhoids.Massaging the fundus (the top of the uterus) may be done to help it contract and prevent bleeding, but this is different from massaging the perineum.

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A nurse is reviewing laboratory results of a pregnant patient.Which result will require further assessment?

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Naxlex Comprehensive Predictor Exams

A nurse caring for a patient in labor is evaluating the fetal heart monitor.Which finding would indicate fetal distress?

Correct Answer is A

Explanation

During the postpartal admission assessment, the nurse notes that a patient’s perineum appears edematous and ecchymotic. Based on this finding, which action should the nurse take?

Correct Answer is D

Explanation

When assessing a newborn, which is the best method for the nurse to use to elicit the Moro reflex?

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he nurse instructs a woman who is attending the infertility clinic about strategies designed to facilitate conception. Which statement by the patient would indicate that she understands the instructions?

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