A patient at 41 weeks' gestation is undergoing an induction of labor with an IV administration of oxytocin (Pitocin). The fetal heart rate starts to demonstrate a recurrent pattern of late decelerations with moderate variability. What is the nurse's priority action?

Correct Answer: A

Rationale: The priority action for the nurse in this situation is to stop the infusion of Pitocin. Late decelerations are a concerning fetal heart rate pattern that indicates uteroplacental insufficiency. Oxytocin (Pitocin) can cause hyperstimulation of the uterus, leading to poor oxygenation of the fetus and resulting in late decelerations. Stopping the Pitocin infusion can help to improve placental perfusion and oxygenation to the fetus, potentially reversing the late decelerations. It is crucial to address the fetal distress promptly to prevent further compromise and ensure the safety of both the mother and the baby. Other interventions, such as repositioning the patient or preparing for a cesarean birth, may also be necessary but should occur after stopping the Pitocin infusion.

Correct Answer: C

Rationale: The correct answer is C) Every 4 weeks until 28 weeks. In a low-risk pregnancy with no complications, prenatal care typically involves more frequent visits early on to monitor the initial stages of pregnancy and then gradually spaces them out as the pregnancy progresses. Option A is incorrect because visiting every 2 weeks for the first 28 weeks is too frequent for a low-risk pregnancy without complications. Option B is incorrect because transitioning to every 4 weeks at 30 weeks is too late to start spacing out appointments. Option D is incorrect because increasing the frequency to every 2 weeks after 28 weeks is unnecessary in the absence of complications. Educationally, understanding the appropriate schedule of prenatal visits is essential for ensuring optimal maternal and fetal health outcomes. By spacing out appointments appropriately, healthcare providers can monitor the progress of the pregnancy, address any emerging issues early, and provide necessary support and guidance to the expectant mother. This knowledge empowers both the healthcare provider and the patient to collaborate effectively in promoting a healthy pregnancy and birth.

Correct Answer: A

Rationale: In this scenario, the correct answer is option A) Asking the client if she needs something to drink. The student nurse should not offer the client something to drink before a pelvic examination as it can lead to complications if the client requires anesthesia during the procedure. Assembling the necessary equipment (option B) is a crucial step in preparing for a pelvic examination, so this action is appropriate. Positioning the client in the lithotomy position (option C) is also a necessary step for a pelvic examination. Explaining the procedure (option D) is an essential part of providing client-centered care and promoting informed consent. However, ensuring the client's safety and well-being by refraining from offering liquids before the examination takes precedence in this situation. Educationally, this question highlights the importance of understanding pre-procedural care and safety considerations in obstetric settings. It emphasizes the significance of adhering to protocols to prevent potential complications and ensure the best possible outcomes for pregnant clients.

Correct Answer: C

Rationale: The correct answer is C) Neural tube defects. The maternal serum alpha-fetoprotein test is a screening test used to detect neural tube defects in the fetus, such as spina bifida or anencephaly. Alpha-fetoprotein is a protein produced by the fetus that crosses into the mother's bloodstream. Elevated levels of alpha-fetoprotein in the maternal serum may indicate a neural tube defect in the developing fetus. Option A) Leg defects, Option B) Gastrointestinal defects, and Option D) Renal defects are incorrect because the maternal serum alpha-fetoprotein test specifically screens for neural tube defects and not for defects in other organ systems. Understanding the purpose of specific prenatal screening tests is crucial in providing comprehensive care to pregnant patients. In an educational context, it is essential for healthcare providers, including nurses, to have a solid understanding of prenatal screening tests and their indications. By knowing the purpose of each test, healthcare professionals can accurately interpret results, provide appropriate information and support to pregnant patients, and facilitate timely interventions if abnormalities are detected. This knowledge ultimately contributes to improving maternal and fetal outcomes by enabling early detection and management of potential complications.

Correct Answer: A

Rationale: In this scenario, option A, a rubella titer ratio of 1:10, would necessitate further testing. This is because a rubella titer ratio of 1:10 indicates that the patient is not immune to rubella, which can pose serious risks during pregnancy. Rubella infection during pregnancy can lead to congenital rubella syndrome in the fetus. Option B, blood type A+, is not indicative of a need for further testing in this context as blood type alone does not raise immediate concerns during the initial assessment of a pregnant patient. Option C, a white blood cell count of 5,000, falls within the normal range and does not signal a need for immediate further testing in the absence of other symptoms or clinical indications. Option D, a previous history of gestational diabetes, is relevant information for the patient's care but does not require immediate further testing during the initial assessment unless there are current concerns about blood sugar levels. Educationally, this question highlights the importance of assessing for potential risks and complications early in pregnancy to provide appropriate care and interventions. It emphasizes the significance of immunity status, especially for infectious diseases like rubella, which can have significant implications for both the mother and the developing fetus.