The nurse is monitoring a client receiving oxytocin for labor induction. What finding requires the nurse to take immediate action?

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: A

Rationale: In this scenario, the nurse's priority action should be to perform a nonstress test (Option A). This test is used to assess fetal well-being by monitoring the fetal heart rate in response to fetal movement. It helps determine if the fetus is receiving an adequate oxygen supply. Performing a nonstress test is crucial because decreased fetal movement could indicate fetal distress or compromise, which requires immediate attention to prevent adverse outcomes. This test provides real-time information on fetal status, guiding further interventions or decisions. Encouraging the client to drink orange juice (Option B) is not the priority action in this situation. While maternal hydration or consuming something sweet may sometimes encourage fetal movement, in cases of decreased fetal movement at 36 weeks, a more formal assessment like a nonstress test is needed to evaluate fetal well-being accurately. Scheduling an ultrasound (Option C) can provide detailed information about fetal status but may not be as immediate or readily available as a nonstress test in determining the current fetal response to stimuli. In cases of decreased fetal movement, time is critical, and the nonstress test offers a quicker assessment of fetal well-being. Notifying the healthcare provider (Option D) is important but should come after initiating the nonstress test. The provider should be informed of the situation and the test results, but the priority is to first assess the fetal well-being through the nonstress test. In the context of maternal newborn care, understanding the significance of fetal movement assessment and the appropriate interventions is vital for ensuring the health and safety of both the mother and the baby. Nurses need to prioritize prompt and accurate assessments to provide timely interventions and prevent potential complications during pregnancy.

Correct Answer: B

Rationale: In the context of preterm labor, it is crucial for the nurse to educate the client about the warning signs that require immediate attention. Lower back pain and cramping (Option B) are concerning symptoms that could indicate preterm labor. These symptoms may signal the onset of contractions and cervical changes that could lead to premature delivery. It is essential for the client to report this symptom promptly to their healthcare provider to receive timely intervention and prevent preterm birth complications. The other options are not indicative of immediate concern for preterm labor. Frequent urination (Option A) is a common symptom during pregnancy due to hormonal changes and the growing uterus pressing on the bladder. Increased appetite (Option C) is also a typical occurrence in pregnancy and does not signal a potential issue with preterm labor. Braxton Hicks contractions (Option D) are usually irregular and do not cause cervical changes leading to preterm labor. Educationally, it is important for nurses to emphasize the significance of recognizing and reporting warning signs of preterm labor to ensure the best possible outcomes for both the mother and the baby. Providing clear information about what symptoms require immediate attention empowers the client to take proactive steps in their prenatal care and seek appropriate medical assistance when needed.

Correct Answer: B

Rationale: The correct answer is B) To assess the baby’s growth and development. An anatomy ultrasound at 20 weeks' gestation is typically performed to evaluate the baby's growth, development, and overall anatomy. This detailed scan allows healthcare providers to assess the baby's organs, limbs, spine, brain, and other structures to ensure they are developing properly. It also helps in detecting any potential abnormalities that may require further evaluation or intervention. Option A) To confirm the baby’s sex is incorrect because while an ultrasound may reveal the baby's sex, its primary purpose at 20 weeks is to assess development, not determine gender. Option C) To detect early signs of labor is incorrect as an anatomy ultrasound does not typically provide information about the onset of labor. Signs of labor are usually monitored through other assessments closer to the due date. Option D) To evaluate amniotic fluid levels is incorrect because amniotic fluid levels are typically assessed through a separate ultrasound called an amniotic fluid index, which is not the primary purpose of an anatomy ultrasound at 20 weeks. In an educational context, it is important for nurses to understand the various types of ultrasounds performed during pregnancy and their specific purposes. This knowledge allows nurses to effectively educate and support pregnant clients in understanding the importance of these screenings for the health and well-being of both the mother and the baby.

Correct Answer: A

Rationale: In the assessment of a client with suspected gestational hypertension, a blood pressure reading of 150/90 mmHg supports this diagnosis. Gestational hypertension is characterized by elevated blood pressure that occurs after 20 weeks of gestation without the presence of proteinuria or end-organ damage. Option A is correct because a blood pressure reading of 150/90 mmHg indicates hypertension in pregnancy, which can lead to adverse outcomes for both the mother and the fetus if not managed appropriately. Option B, proteinuria of +2, is more indicative of preeclampsia rather than gestational hypertension. Preeclampsia is characterized by hypertension and proteinuria, while gestational hypertension is defined by elevated blood pressure alone. Option C, fetal heart rate of 140 beats/minute, is not directly related to the diagnosis of gestational hypertension. Fetal heart rate monitoring is important for assessing fetal well-being but does not confirm the diagnosis of gestational hypertension. Option D, mild edema in the lower extremities, is a common finding in pregnancy and is not specific to gestational hypertension. Edema alone is not a reliable indicator of this condition. Educationally, understanding the differences between gestational hypertension and preeclampsia is crucial for nurses caring for pregnant clients. Recognizing the key signs and symptoms of each condition is essential for early detection, appropriate management, and optimal outcomes for both the mother and the baby. Regular monitoring of blood pressure and other clinical signs is vital in the antenatal care of women at risk for hypertensive disorders of pregnancy.