A woman, G1 P0000, 40 weeks' gestation, entered the labor suite stating that she is in labor. Upon examination it is noted that the woman is 2 cm dilated, 30% effaced, contracting every 12 min 30 sec. Fetal heart rate is in the 140s with good variability and spontaneous accelerations. What should the nurse conclude when reporting the findings to the primary health care practitioner?

Correct Answer: B

Rationale: In this scenario, the woman is 40 weeks gestation, with 2 cm dilation, 30% effacement, contracting every 12 minutes and 30 seconds. The fetal heart rate is in the 140s with good variability and spontaneous accelerations. Choice A: The woman is not high risk based on the information provided. Tocolytics are used to stop preterm labor, not indicated in this case. Choice C: Induction is not necessary at this point as the woman is only 2 cm dilated and 30% effaced, indicating early labor. Choice D: The woman is not in active labor as she is only 2 cm dilated and contracting every 12 minutes and 30 seconds. Correct Answer (B): The findings suggest that the woman is in early labor. With 2 cm dilation, 30% effacement, and contractions every 12 minutes and 30 seconds, she is not in active labor. The fetal heart rate is reassuring with good variability and spontaneous accelerations. The nurse can conclude that the woman is in early labor and could potentially be sent home to continue laboring until she is in active labor. This approach allows her to be in a familiar and comfortable environment until labor progresses further.

Correct Answer: B

Rationale: The correct answer is B: Fetal heart acceleration. During a fetal scalp stimulation test, the practitioner will apply pressure to the fetal scalp to stimulate the baby. A normal response to this stimulation is an acceleration in the fetal heart rate. This is because the stimulation causes an increase in sympathetic nervous system activity, leading to an increase in heart rate. This is a reassuring sign of fetal well-being as it indicates that the baby is responding appropriately to stimuli. Now, let's discuss why the other choices are incorrect: A: Spontaneous fetal movement. While fetal movement is a sign of fetal well-being, the fetal scalp stimulation test specifically looks for a response in the fetal heart rate, not fetal movement. Therefore, this choice is not the expected response during this test. C: Increase in fetal heart variability. Fetal heart rate variability is a measure of the fluctuations in the fetal heart rate over time. While variability is a positive sign of fetal well-being, it is not the expected response during a fetal scalp stimulation test. The test is specifically looking for a change in the fetal heart rate in response to stimulation, not an increase in variability. D: Resolution of late decelerations. Late decelerations are a concerning fetal heart rate pattern that indicates uteroplacental insufficiency. The fetal scalp stimulation test is not designed to resolve late decelerations. It is used to assess fetal well-being by evaluating the fetal heart rate response to stimulation. In conclusion, the correct response to a fetal scalp stimulation test is an acceleration in the fetal heart rate. This indicates that the baby is responding appropriately to stimulation and is a reassuring sign of fetal well-being.

Correct Answer: C

Rationale: Choice A is incorrect because encouraging the father to hold his partner's hand during labor is not specifically related to the patient's religious or cultural beliefs as an Orthodox Jewish woman. While emotional support is important during labor, this choice does not address any specific cultural needs of the patient. Choice B is incorrect because asking the woman if she would like to speak with her priest assumes that the patient is Catholic or another faith that has priests. In this case, the patient is identified as being Orthodox Jewish, so it would not be appropriate to offer the services of a priest, as this does not align with her religious beliefs. Choice D is incorrect because placing an order for the woman's postpartum vegetarian diet assumes that all Orthodox Jewish individuals follow a vegetarian diet, which is not necessarily the case. While some may choose to follow a vegetarian diet for religious or personal reasons, it is not a universal practice among Orthodox Jewish individuals. Choice C is the correct answer because providing the woman with a long-sleeved hospital gown aligns with the modesty and privacy guidelines of Orthodox Jewish women. Modesty is an important aspect of Orthodox Jewish culture, and providing appropriate attire that respects this aspect of her beliefs is an important part of culturally competent care.

Correct Answer: A

Rationale: To calculate the drip rate for the IV infusion, you first need to determine the total volume of fluid to be infused per hour. The order is to infuse 1000 cc of D5 1/2 NS at a rate of 150 cc/hr. Next, you need to convert the volume to drops per minute using the drop factor of 10 gtt/cc. First, calculate the total volume to be infused per hour: 1000 cc ÷ 150 cc/hr = 6.67 hours Next, convert the volume to drops per minute: 1000 cc × 10 gtt/cc = 10,000 gtt 10,000 gtt ÷ 60 min = 166.67 gtt/min Therefore, the correct drip rate is 167 gtt/min (rounded to the nearest whole number), which corresponds to answer choice A. Choices B, C, and D are marked as N/A because they do not provide a numerical value for the drip rate. These choices are incorrect as they do not offer a solution to the question posed. The correct answer, choice A, is based on accurate calculations and proper conversion of units to determine the appropriate drip rate for the IV infusion.

Correct Answer: A

Rationale: Before proceeding with a physical assessment, the nurse should check the client's weight gain in the prenatal record. This is important because weight gain during pregnancy is a significant indicator of the health of both the mother and the developing fetus. Monitoring weight gain helps healthcare providers assess if the mother is gaining an appropriate amount of weight for a healthy pregnancy and if there are any potential complications such as gestational diabetes or preeclampsia. Choice B, the client's ethnicity and religion, is incorrect because while cultural considerations are important in providing individualized care, they do not directly impact the physical assessment process. Choice C, the client's age, is also incorrect as age alone does not provide enough information to determine the client's health status during pregnancy. Choice D, the type of insurance the woman has, is incorrect because insurance status is not a determining factor in conducting a physical assessment. While insurance coverage may impact the client's access to healthcare services, it does not directly influence the physical assessment process. Monitoring weight gain is essential for assessing the health and well-being of both the mother and the developing fetus during pregnancy.