A client at 36 weeks' gestation reports frequent urination and lower back pain. What should the nurse assess for?

Correct Answer: A

Rationale: In this scenario, the correct answer is A) Preterm labor. At 36 weeks' gestation, frequent urination and lower back pain could be indicative of preterm labor, which is a serious concern in late pregnancy. The nurse should assess for signs such as regular contractions, abdominal cramping, vaginal bleeding, pelvic pressure, or a change in vaginal discharge to confirm preterm labor. Option B) Urinary tract infection is incorrect because although frequent urination can be a symptom, lower back pain is not typically associated with a UTI in pregnancy. UTIs usually present with symptoms like burning sensation during urination, cloudy or strong-smelling urine, and pelvic discomfort. Option C) Normal third-trimester changes is incorrect because while frequent urination can be a normal symptom in late pregnancy due to the pressure on the bladder from the growing uterus, lower back pain should not be dismissed as a typical discomfort. It is essential to rule out complications like preterm labor. Option D) Preeclampsia is incorrect as it usually presents with symptoms such as high blood pressure, proteinuria, swelling in the hands and face, headaches, and visual disturbances. Lower back pain and frequent urination are not typically associated with preeclampsia. In an educational context, understanding the signs and symptoms of preterm labor is crucial for nurses caring for pregnant women. Early identification and intervention can help prevent preterm birth and its associated complications. Nurses must be able to differentiate between normal pregnancy discomforts and potential red flags that require immediate attention to provide optimal care for both the mother and the baby.

Correct Answer: A

Rationale: In this scenario, the correct answer is A) Cholestasis of pregnancy. Severe itching without a rash in the third trimester should raise suspicion for cholestasis of pregnancy, a liver disorder that occurs during pregnancy and can lead to complications for both the mother and the fetus. Cholestasis of pregnancy is characterized by impaired bile flow, leading to a buildup of bile acids in the bloodstream, which can cause intense itching, typically on the palms and soles. Option B) Preeclampsia is a condition characterized by high blood pressure and signs of damage to another organ system, most commonly the liver and kidneys. While preeclampsia can present with symptoms such as headache, visual changes, and swelling, severe itching without a rash is not a typical symptom. Option C) Gestational diabetes is a condition where women without previously diagnosed diabetes develop high blood sugar levels during pregnancy. It is primarily associated with issues related to blood sugar control and typically does not present with severe itching without a rash. Option D) Fungal infection is unlikely in this case as severe itching without a rash is not a common presentation for a fungal infection, especially in the absence of other symptoms like redness, scaling, or discharge. Understanding these distinctions is crucial for nurses caring for pregnant clients, as prompt identification of conditions like cholestasis of pregnancy can lead to appropriate management and improved outcomes for both the mother and the baby. Nurses must be able to differentiate between various conditions that can arise during pregnancy to provide optimal care and support to their patients.

Correct Answer: B

Rationale: In this scenario, the correct answer is option B) Contractions lasting 120 seconds. This finding would prompt the nurse to stop the oxytocin infusion because prolonged contractions can lead to uterine hyperstimulation, which can compromise fetal oxygenation and result in fetal distress. It is crucial to maintain an appropriate balance between uterine contractions for labor progress and ensuring fetal well-being during labor induction. Option A) Contractions every 2-3 minutes can be a normal response to oxytocin induction, but it alone does not indicate a need to stop the infusion. Option C) Baseline fetal heart rate of 140 beats/minute is within the normal range for a fetus at term and does not require stopping the infusion. Option D) Client reports mild back pain is a common discomfort during labor and is not a reason to discontinue the oxytocin infusion. Educationally, understanding the potential risks and complications of oxytocin administration during labor induction is essential for nurses caring for laboring women. It is crucial for nurses to recognize abnormal findings and take prompt actions to ensure the safety and well-being of both the mother and the fetus. Continuous monitoring and assessment skills are vital in obstetric care to provide safe and effective care during the labor and delivery process.

Correct Answer: C

Rationale: In this scenario, the correct answer is C) Fetal heart rate of 180 beats/minute. This finding requires immediate action because it indicates fetal distress, which is a serious concern during labor. A fetal heart rate of 180 beats/minute suggests fetal tachycardia, which can be a sign of insufficient oxygenation and potential hypoxia in the fetus. This situation requires prompt intervention to prevent adverse outcomes for the baby. Option A) Contractions lasting 90 seconds is not an immediate concern as long as there are no signs of fetal distress or hyperstimulation. Prolonged contractions can occur in some cases without causing harm. Option B) Contractions every 2-3 minutes can indicate hyperstimulation, but it may not be as urgent as fetal distress. Adjusting the oxytocin infusion rate can help manage this issue. Option D) Client reports mild nausea is not a critical finding in this context. Nausea can be a common side effect of oxytocin but does not pose an immediate threat to the fetus. Educationally, understanding the implications of fetal heart rate patterns and recognizing signs of fetal distress are crucial skills for nurses caring for laboring women. It is essential to prioritize interventions based on the urgency of the situation to ensure the best possible outcomes for both mother and baby.

Correct Answer: C

Rationale: In this scenario, option C, "True labor contractions increase in intensity and frequency," is the correct answer. This statement indicates understanding because true labor contractions, which signify the onset of active labor, typically become stronger and more frequent over time, leading to cervical dilation and effacement. This progression is crucial for the advancement of labor and eventual delivery of the baby. Option A, "True labor contractions are irregular and stop with rest," is incorrect. True labor contractions are regular, increasing in intensity, duration, and frequency as labor progresses. They do not subside with rest; in fact, they often become more pronounced with activity. Option B, "False labor contractions cause cervical dilation," is incorrect. False labor contractions, also known as Braxton Hicks contractions, do not cause cervical changes or lead to the onset of active labor. They are irregular and do not follow a pattern of increasing intensity and frequency. Option D, "False labor contractions are felt in the back," is also incorrect. While back pain can be a component of both true and false labor contractions for some individuals, it is not a definitive characteristic to differentiate between the two types of contractions. In an educational context, understanding the characteristics of true labor contractions is essential for expectant parents to recognize the signs of labor onset and seek appropriate medical care. Educating prenatal class participants about the progression of labor helps them feel more prepared and confident as they approach childbirth.