Scenario:
A nurse is caring for a 26-year-old gravida 2 para 1 female client in the labor and delivery unit. The client previously delivered vaginally three years ago under epidural anesthesia. Her current pregnancy has progressed normally with a weight gain of 28 lbs (12.7 kg) and no reported blood pressure issues. Group B Streptococcus screening is negative, and all pregnancy-related laboratory results, including rubella immunity, are within normal limits. The client has a blood type of O, Rh-positive.
The nurse teaches the client about the fetus's reaction to labor by:
Select the most appropriate options missing from the statements below. Describing heart rate patterns by
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}
Complete the sentence: The nurse teaches the client about the fetus's reaction to labor by explaining that early decelerations indicate head compression and assessing fetal heart rate patterns before, during, and after contractions.
Rationale for correct answer: Explaining that early decelerations indicate head compression is correct because early decelerations are typically associated with head compression during contractions. This is a common finding during labor and usually not a sign of fetal distress. It indicates that the fetus is descending through the birth canal, causing temporary compression of the fetal head, which leads to a brief decrease in heart rate.
Assessing fetal heart rate patterns before, during, and after contractions is correct because it provides a comprehensive understanding of how the fetus responds to labor. Monitoring the fetal heart rate throughout the contraction cycle helps identify patterns of variability, decelerations, and accelerations, ensuring that the fetus is tolerating labor well.
Rationale for incorrect answers: Choice A rationale: Identifying early decelerations as a sign of fetal distress is incorrect because early decelerations are generally benign and related to head compression. They are not typically a sign of fetal distress. Late or variable decelerations are more concerning and may indicate fetal distress.
Choice C rationale: Stating that early decelerations require immediate intervention is incorrect because early decelerations do not usually require immediate intervention. They are a normal finding during labor caused by head compression. Interventions are necessary for late or variable decelerations, which indicate possible fetal compromise.
Choice D rationale: Noting that early decelerations suggest umbilical cord compression is incorrect because early decelerations are not typically associated with umbilical cord compression. Variable decelerations are more likely to indicate cord compression, requiring closer monitoring and possible intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
Choice A rationale
Documenting the wound measurements with tunneling is important for tracking the wound's progression and planning appropriate interventions. Accurate documentation helps in assessing the effectiveness of the treatment plan.
Choice B rationale
Cleansing the wound and discontinuing the VAC system is necessary when foul, purulent drainage is observed. This action helps to prevent further infection and allows the healthcare provider to reassess the wound care approach.
Choice D rationale
Consulting the wound care specialist to evaluate the wound is essential for expert advice on managing complex wounds. Specialists can provide tailored recommendations to promote wound healing and prevent complications.
Choice C rationale
Increasing the wound VAC suction to eliminate the drainage is not appropriate as it may worsen the infection or damage the surrounding tissues. Proper wound care protocols should be followed to ensure safe and effective treatment.
Choice E rationale
Reapplying the VAC system after irrigating away drainage is not advisable if there is evidence of infection. The wound should be thoroughly assessed, and appropriate measures should be taken to address the underlying infection.
Correct Answer is D
Explanation
Choice A rationale: While psychological assessment is important, it is not the primary focus for assessing outcomes in this case. The client's physical health conditions and the impact on her daily living and functional ability are more directly relevant.
Choice B rationale: Financial security is not the primary concern in this context. The primary focus is on the client's health and ability to perform activities of daily living (ADLs), which is addressed by evaluating functional improvement.
Choice C rationale: Quality of life is a broad concept that includes many aspects such as emotional, social, and physical well-being. While it is relevant, the primary outcome measure in this context is the client's functional improvement related to her health conditions and ability to manage ADLs.
Choice D rationale: Functional improvement is the correct focus for evaluating the client's outcomes. This includes her ability to perform activities of daily living (ADLs) and manage her health conditions. The nurse should assess how well the client can maintain or improve her functional abilities with the additional care provided.
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