The nurse is monitoring a pregnant client undergoing a nonstress test. What is a reassuring finding?

Correct Answer: A

Rationale: In the context of monitoring a pregnant client undergoing a nonstress test, the reassuring finding is option A) Two accelerations in 20 minutes. Accelerations are indicative of a healthy fetal response to stimulation, suggesting an intact central nervous system. This pattern of accelerations indicates fetal well-being and adequate oxygenation. Option B) Baseline fetal heart rate of 170 beats/minute is not a reassuring finding as it is above the normal range for fetal heart rate. A baseline heart rate above 160 bpm may indicate fetal distress. Option C) Decreased fetal movement is a concerning finding as it could signal potential issues with fetal well-being, such as fetal distress or hypoxia. Option D) Variable decelerations are also not reassuring as they may indicate umbilical cord compression or other issues affecting fetal oxygenation. In an educational context, understanding the interpretation of fetal monitoring findings is crucial for nurses caring for pregnant clients. Nonstress tests are used to assess fetal well-being by evaluating the fetal heart rate response to movement. Nurses must be able to accurately interpret these findings to provide appropriate care and interventions for both the mother and the fetus.

Correct Answer: C

Rationale: In the case of a client at 36 weeks' gestation with suspected polyhydramnios, the complication associated with this condition is cord prolapse (Option C). Polyhydramnios refers to an excess of amniotic fluid, which can increase the risk of cord prolapse during labor and delivery. Cord prolapse occurs when the umbilical cord slips through the cervix ahead of the baby, which can lead to compression of the cord and compromise fetal blood flow and oxygenation. Option A, preterm labor, is not directly associated with polyhydramnios. Preterm labor refers to the onset of labor before 37 weeks of gestation due to various reasons, but not specifically linked to polyhydramnios. Option B, placenta previa, involves the abnormal placement of the placenta over or near the cervical opening, causing bleeding during labor. While placenta previa is a potential complication in pregnancy, it is not directly related to polyhydramnios. Option D, gestational hypertension, is characterized by high blood pressure during pregnancy and can lead to complications such as preeclampsia. While gestational hypertension is a significant concern in pregnancy, it is not the primary complication associated with polyhydramnios. Educationally, understanding the complications of polyhydramnios is crucial for nurses caring for pregnant clients. Recognizing the risks associated with this condition allows for prompt intervention and management to ensure the best outcomes for both the mother and the baby. Monitoring for potential complications like cord prolapse in cases of polyhydramnios is essential for providing safe and effective care during labor and delivery.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Assess for signs of preterm labor. The priority nursing action when a client at 28 weeks' gestation reports uterine contractions every 10 minutes is to assess for signs of preterm labor. This is crucial because preterm labor can have serious implications for both the mother and the baby. By assessing for signs of preterm labor, the nurse can determine the appropriate course of action to prevent premature birth and its associated complications. Option A) Encourage rest and hydration is not the priority in this situation because the client's symptoms indicate a potentially serious issue that requires immediate attention. Option C) Administer tocolytic medication is not the priority until preterm labor is confirmed. Tocolytic medications are used to halt preterm labor, but their administration should be based on a thorough assessment and diagnosis. Option D) Perform a vaginal examination is not the initial priority as it can potentially stimulate the uterus and worsen the contractions. It should only be done after assessing for signs of preterm labor and confirming the need for further evaluation. In an educational context, understanding how to prioritize nursing actions in situations of potential preterm labor is crucial for providing safe and effective care to pregnant clients. Nurses must be able to quickly assess and intervene in such situations to prevent adverse outcomes for both the mother and the baby. This question highlights the importance of timely assessment and intervention in maternal care.

Correct Answer: C

Rationale: In the context of preparing a client for induction of labor, the primary purpose of administering oxytocin is to strengthen uterine contractions (Option C). Oxytocin is a hormone that acts on the smooth muscle of the uterus, causing it to contract. This helps to initiate and progress labor by promoting regular and coordinated contractions, leading to cervical effacement and dilation, ultimately resulting in the delivery of the baby. Option A, enhancing cervical dilation, is not the primary purpose of administering oxytocin. While oxytocin can contribute to cervical dilation indirectly by promoting uterine contractions, its main role is to stimulate uterine muscle activity. Option B, increasing maternal blood pressure, is not a function of oxytocin in the context of labor induction. Oxytocin's effects are primarily focused on the uterus and its contractile activity. Option D, preventing postpartum hemorrhage, is not the primary purpose of administering oxytocin for labor induction. Oxytocin is commonly used after delivery to help prevent postpartum hemorrhage by promoting uterine contraction and controlling bleeding, but its main role during labor induction is to stimulate uterine contractions to initiate labor. Understanding the specific pharmacological actions of oxytocin in labor induction is crucial for nurses caring for women undergoing this process. It is important for nurses to be knowledgeable about the indications, actions, and potential side effects of medications used in obstetric care to ensure safe and effective management of labor and delivery.

Correct Answer: C

Rationale: In this scenario, the correct answer is option C: Pulmonary hypoplasia. Oligohydramnios, which is a condition characterized by a decreased amount of amniotic fluid surrounding the fetus, can lead to various complications. Pulmonary hypoplasia is a significant concern in cases of oligohydramnios because amniotic fluid plays a crucial role in fetal lung development. Adequate levels of amniotic fluid are necessary for the normal growth and expansion of the fetal lungs. When oligohydramnios is present, there is a risk of underdeveloped or hypoplastic lungs, which can result in respiratory distress for the newborn after birth. Now, let's discuss why the other options are incorrect: A) Fetal macrosomia: This condition refers to a large baby at birth, which is not directly associated with oligohydramnios. Fetal macrosomia is more commonly linked to maternal conditions like gestational diabetes. B) Cord prolapse: Cord prolapse occurs when the umbilical cord slips through the cervix ahead of the baby. While oligohydramnios can increase the risk of cord compression, it is not directly associated with cord prolapse. D) Placenta previa: Placenta previa is a condition where the placenta partially or completely covers the cervix, which can lead to bleeding during pregnancy. Oligohydramnios is not a typical complication of placenta previa. In an educational context, understanding the implications of oligohydramnios on fetal development is crucial for healthcare providers caring for pregnant women. This knowledge helps in identifying potential complications, providing appropriate interventions, and ensuring the best possible outcomes for both the mother and the baby. It underscores the importance of prenatal monitoring and timely interventions to address conditions that can impact fetal well-being.