A nurse is assisting in the care of a client who is in labor and requires intermittent fetal monitoring. Which of the following actions should the nurse take?
Auscultate fetal heart tones during a contraction.
Place a Doppler ultrasound over the fundus.
Perform Leopold maneuvers to determine fetal position.
Count the fetal heart rate for 15 seconds.
The Correct Answer is C
Choice A rationale
Auscultating fetal heart tones during a contraction does not provide a clear assessment of the fetal heart rate pattern and can be affected by the contraction itself.
Choice B rationale
Placing a Doppler ultrasound over the fundus is not effective, as the fundus is not the optimal location to hear fetal heart tones, especially in early labor.
Choice C rationale
Performing Leopold maneuvers to determine fetal position is crucial as it helps in placing the Doppler in the correct position for accurate monitoring of fetal heart tones.
Choice D rationale
Counting the fetal heart rate for 15 seconds and then multiplying by 4 may not provide an accurate assessment of the fetal heart rate pattern or variability, which is important for fetal well-being assessment. .
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Correct Answer is C
Explanation
Choice A rationale
A weak cry is not a typical manifestation of neonatal abstinence syndrome (NAS). NAS usually presents with a high-pitched, persistent cry due to central nervous system irritability.
Choice B rationale
Decreased muscle tone is not common in NAS. Infants with NAS often exhibit hypertonia, characterized by increased muscle tone and rigidity.
Choice C rationale
This statement is correct because an exaggerated Moro reflex is a common sign of NAS, indicating central nervous system hyperactivity in response to withdrawal from maternal drugs.
Choice D rationale
An infant with NAS does not console easily. They are often difficult to soothe due to irritability and discomfort from withdrawal symptoms. .
Correct Answer is D
Explanation
Choice A rationale
A maternal age of 30 years is not a significant risk factor for preeclampsia. Preeclampsia is more common in very young mothers or those over the age of 35.
Choice B rationale
A prepregnancy BMI of 19 is within the normal range and is not considered a risk factor for preeclampsia, which is more commonly associated with higher BMI or obesity.
Choice C rationale
Being in the third pregnancy (multiparity) is not a strong risk factor for preeclampsia. The risk factors are more closely related to the individual's health conditions and first pregnancies.
Choice D rationale
Chronic hypertension is a well-known risk factor for preeclampsia as it indicates pre-existing cardiovascular issues that can predispose one to developing preeclampsia during preg