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Ati nur 232 maternity final exam sp24
Total Questions : 96
Showing 10 questions, Sign in for more• Fetal heart tones (FHT): 145/min
• Uterine contractions every 2 minutes, lasting 80 seconds, moderate intensity
- Client reports low back pain and frequent urination since last night.
- Urination is painful and only a small amount is passed each time.
- Abdomen is soft and nontender.
- Vaginal examination: 2 cm dilated, 100% effaced, 0 station.
- Bloody mucus noted on sterile glove.
• G2P1, 34 weeks pregnant
• No known allergies
• Previous pregnancy was full-term with no complications
• Place client on electronic fetal monitor
• Administer IV fluids
• Monitor vital signs every hour
• Notify provider of any changes in client status
A 28-year-old female client is admitted to the labor and delivery unit at 0700hrs. She is 34 weeks pregnant and reports having low back pain and frequent urination since last night. She mentions that urination is painful and she can only pass a small amount each time.
Given the client’s symptoms and the progression of her condition, the nurse suspects that the client may be experiencing complications related to preterm labor and a possible urinary tract infection (UTI). For each characteristic in the table, select whether it is more likely to be associated with preterm labor, a urinary tract infection (UTI), or both. Each column must have at least one response option selected. Candidates can select as many options as apply for each column.
Explanation
• Frequent urination: This is more likely to be associated with a UTI, as frequent urination is a common symptom of UTIs.
• Low back pain: This can be associated with both preterm labor and a UTI. Low back pain can be a sign of labor, and it can also be a symptom of a UTI.
• Temperature of 38.3°C (101°F): This is more likely to be associated with a UTI, as fever is a common symptom of infections, including UTIs.
• Strong urge to push: This is more likely to be associated with preterm labor, as an urge to push can be a sign of labor.
• Contractions every 1.5 minutes: This is more likely to be associated with preterm labor, as frequent contractions are a sign of labor.
• Pain level of 8 on a scale of 0 to 10: This can be associated with both preterm labor and a UTI. Severe pain can be a sign of labor, and it can also be a symptom of a UTI. Please note that these are potential associations and the healthcare provider should be informed immediately for further evaluation and management. It’s important to continue following the provider’s prescriptions and closely monitor the client’s condition.
• Gravida: 2, Para: 1
• Had an uncomplicated spontaneous vaginal birth 3 years ago of a 7 lb 4 oz infant
• Client has no outstanding medical, social, or surgical history
• Plan is to induce labor using oxytocin
• Client is resting in bed, appears anxious about the induction process.
• Reports mild, irregular contractions, stating they began around midnight.
• Fetal heart rate (FHR) is 140 beats per minute, with moderate variability.
• Cervix is 2 cm dilated, 50% effaced, and the fetal head is at -2 station.
• Client’s partner is present and providing support.
• IV line is in place, and oxytocin infusion is started at 2 mU/min.
• Client is encouraged to ambulate as tolerated.
• Client reports increased intensity and frequency of contractions, now occurring every 3-4 minutes.
• FHR is 145 beats per minute, with moderate variability and occasional accelerations.
• Cervix is now 4 cm dilated, 70% effaced, and the fetal head is at -1 station.
• Client is experiencing back pain and requests pain relief.
• IV oxytocin infusion is increased to 6 mU/min as per protocol.
• Client is repositioned to a side-lying position for comfort.
• Partner continues to provide support and encouragement.
- Temperature: 37.2°C (99°F)
- Blood Pressure: 120/80 mmHg
- Heart Rate: 82 beats per minute
- Respiratory Rate: 18 breaths per minute
• Temperature: 37.5°C (99.5°F)
• Blood Pressure: 122/78 mmHg
• Heart Rate: 88 beats per minute
• Respiratory Rate: 20 breaths per minute
- Fetal scalp pH: 7.25
- Amniotic fluid: Clear, no meconium present
A nurse is caring for a client who is 42 weeks of gestation.
Based on the updated assessment findings, which of the following actions should the nurse plan to take? Click to specify whether the nurse’s planned actions are anticipated, nonessential, or contraindicated.
Explanation
• Increase the oxytocin infusion to 13 mU/min: This is an anticipated action. The client’s contractions are becoming more frequent and intense, and her cervix is dilating and effacing. Increasing the oxytocin infusion can help to further progress labor.
• Place client in a side-lying position: This is an anticipated action. The side-lying position can help to improve maternal and fetal circulation and can also help to alleviate back pain.
• Initiate bolus of primary IV fluids: This is an anticipated action. The client is in labor and may not be able to consume adequate fluids orally. Providing IV fluids can help to prevent dehydration.
• Apply oxygen at 10 L/min via venturi mask: This is a nonessential action. The client’s respiratory rate and oxygen saturation are within normal limits, and she is not reporting any difficulty breathing.
• Perform sterile vaginal exam: This is an anticipated action. Regular vaginal exams are necessary to assess the progress of labor, including changes in cervical dilation, effacement, and fetal station.
• Assign a Bishop score: This is a nonessential action. The Bishop score is typically used to evaluate the readiness of the cervix for induction of labor. As the client is already in labor and her cervix is dilating and effacing, assigning a Bishop score is not necessary at this time.
• Perform an amniotomy: This is a nonessential action. An amniotomy (artificial rupture of membranes) can be used to induce or augment labor, but it is not necessary if labor is progressing normally, as it appears to be in this client. Please note that these are potential actions and the healthcare provider should be informed immediately for further evaluation and management. It’s important to continue following the provider’s prescriptions and closely monitor the client’s condition.
The client reports feeling generally well but mentions occasional episodes of dizziness and increased thirst. She has been monitoring her blood glucose levels at home and notes that they have been higher than usual. The client is concerned about the impact of her blood glucose levels on her pregnancy. She has been following a diet plan but admits to occasional deviations. The client denies any abdominal pain or contractions. Fetal movements are reported as normal. The client is advised to continue monitoring her blood glucose levels and to report any significant changes.
• Temperature: 37.2°C (98.96°F)
• Blood Pressure: 130/85 mmHg
• Heart Rate: 88 bpm
• Respiratory Rate: 18 breaths/min
• Fasting blood glucose: 138 mg/dL (60 to 105 mg/dL)
• HbA1c: 6.4% (less than 6.5%)
• Urinalysis:
o Appearance: Clear
o Color: Amber yellow
o pH: 8.0 (4.6 to 8.0)
o Positive urine glucose (expected negative)
o 3+ ketones (expected negative)
o Urine specific gravity: 1.020 (1.005 to 1.030)
Which of the following provider prescriptions should the nurse plan to implement? Select the 3 actions the nurse should plan to take.
Which of the following provider prescriptions should the nurse plan to implement? Select the 3 actions the nurse should plan to take.
• Temperature: 36.6°C (97.9°F)
• Pulse: 85/min
• Respiratory rate: 20/min
• Blood pressure: 180/99 mm Hg
• Client reports, “I have had a headache for 2 days. Tylenol does not relieve it.”
• Client states, “I have blurred vision and dizziness.”
• Client reports swelling of their feet.
• 2+ pitting edema of the lower extremities noted bilaterally.
• Deep tendon reflexes 3+, absent clonus.
• Fetal heart tones (FH) 150/min.
• Gravida 4 Para 3
• 33 weeks of gestation
• Allergies: Sulfa
• Height: 165 cm (66 in)
• Weight: 82 kg (180 lb)
• BMI: 30.6
Select the 4 assessment findings the nurse should report to the provider.
A nurse in the newborn unit is caring for several infants.
Which of the following situations requires the nurse's immediate attention and intervention?
A nurse is completing discharge teaching to a client in her 35th week of pregnancy who has mild preeclampsia. Which of the following information about nutrition should be included in the teaching?
A nurse is teaching a client who is postpartum and has a new prescription for Rh(D) immunoglobulin. Which of the following should be included in the teaching?
A nurse in a prenatal clinic is caring for a client who is at 39 weeks of gestation and who asks about the signs that precede the onset of labor.
Which of the following should the nurse identify as a sign that precedes labor?
A nurse is caring for a client who is receiving heparin 3,800 units subcutaneously daily.
Available is heparin 5,000 units/mL. How many ml should the nurse administer? (Round the answer to the nearest tenth.) .
Explanation
Step 1 is to determine the amount of heparin to administer. The client is receiving 3,800 units of heparin, and the available heparin is 5,000 units/mL.
Step 2 is to set up the calculation: (3,800 units ÷ 5,000 units/mL) = x mL.
Step 3 is to perform the calculation: x = 0.76 mL. Therefore, the nurse should administer 0.8 mL of heparin, rounded to the nearest tenth.
A nurse is caring for a client who gave birth 2 hours ago.
The nurse notes that the client’s blood pressure is 60 mm Hg. Which of the following actions should the nurse take first?
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