nurse hears a client in active labor say to her husband, “Don’t touch me.
Stay away.” The husband states, “I don’t know what to do. Everything I do is wrong.” Which response by the nurse would be the most supportive?

“Would you like to take a break for a while?”.

“You are doing a great job.

It’s very difficult to support someone during this part of labor.”.

“Perhaps she’ll respond better to someone else.

Can you call someone to help?”.

Answer and Explanation

The Correct Answer is B

The correct answer is choice B. “You are doing a great job.

It’s very difficult to support someone during this part of labor.” This response acknowledges the husband’s feelings and efforts, and provides reassurance and encouragement.

It also reflects the reality that active labor can be very intense and painful for the woman, and she may not want to be touched or talked to.

Choice A is wrong because it suggests that the husband is not needed or wanted, and may make him feel rejected or useless.

Choice C is wrong because it implies that the husband is not a good support person, and may hurt his self-esteem or damage his relationship with his wife.

Choice D is wrong because it focuses on the physical aspect of labor, rather than the emotional one.

It also assumes that the woman wants medication, which may not be the case.

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Correct Answer is C

Explanation

The correct answer is choice C. Urine testing is the best indication of whether my blood sugar is under control. This is wrong because urine testing only reflects the blood sugar level at the time of urination, not the current level.

It also does not detect low blood sugar levels (hypoglycemia), which can be dangerous for the mother and the baby.

The best way to monitor blood sugar levels during pregnancy is to use a glucometer, which measures the blood glucose level from a drop of blood.

Choice A is correct because insulin requirements usually increase during pregnancy due to hormonal changes and increased insulin resistance.

The patient may need to adjust her insulin dose according to her blood glucose levels and dietary intake.

Choice B is correct because the patient needs to eat a balanced diet that provides adequate calories and nutrients for herself and the baby.

She may need to consult a dietitian to plan her meals and snacks according to her blood glucose levels and insulin regimen.

Choice D is correct because regular exercise can help lower blood glucose levels, improve insulin sensitivity, and prevent excessive weight gain during pregnancy.

The patient should consult her healthcare provider before starting or changing her exercise routine.

A. The fetal heart rate decreases after the start of a contraction and returns to the baseline 60 seconds after the end of the contraction. B. There is a six to ten beat-to-beat variability in the fetal heart rate. C. The fetal heart rate accelerates five to seven beats just prior to the beginning of a contraction. D. The fetal heart rate decreases at the start of the contraction and returns to baseline by the end of the contraction.

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)

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nurse hears a client in active labor say to her husband, “Don’t touch me. Stay away.” The husband states, “I don’t know what to do. Everything I do is wrong.” Which response by the nurse would be the most supportive?

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Correct Answer is C

Explanation

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

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

A patient who is 17 weeks pregnant shares several pieces of information with the nurse. Which statement made by the patient would indicate the patient is at risk for having an infant with intrauterine growth retardation (IUGR)?

The mother of a 4-hour-old newborn reports to a nurse, “My son is producing breast milk.” The nurse’s response should be based on which understanding about newborn physiology? This is:.

A nurse is caring for a patient who is receiving oxytocin injection intravenously for labor induction.The nurse should monitor this patient for which adverse effect of oxytocin?

A client treated for preterm labor is to be discharged to home. Which instruction should a nurse include in this client’s discharge plan? The client should:.

During a regular clinic visit, a patient who is 28 weeks pregnant reports leg cramps. The nurse teaches the patient measures to relieve the cramps. Which statement would indicate that the patient understands the teaching?

A patient had a cesarean delivery due to placenta previa.Which statement by the patient would indicate that she understands why she had the cesarean delivery?

A woman gives birth to twin girls, one of whom is stillborn. Which nursing action would be least helpful in supporting the woman as she copes with her loss?

nurse hears a client in active labor say to her husband, “Don’t touch me.
Stay away.” The husband states, “I don’t know what to do. Everything I do is wrong.” Which response by the nurse would be the most supportive?