A nurse is caring for a client with irregular uterine contractions that are mild to palpation. FHR is 130/min with moderate variability and accelerations noted. The client has been ambulating in the hallway, took a warm shower, and is now resting in bed. The client rates pain of contractions at 3 on a 0 to 10 scale.
What potential condition does the nurse suspect?
Umbilical cord compression.
Dysfunctional labor.
Chorioamnionitis.
Iron deficiency anemia.
The Correct Answer is B
Choice A rationale
Umbilical cord compression typically results in variable decelerations in the fetal heart rate, not moderate variability or regular accelerations. It can lead to changes in fetal heart rate
patterns, but not regular mild contractions.
Choice B rationale
Dysfunctional labor refers to an abnormal labor pattern, including irregular uterine contractions. The described symptoms fit this condition, as they can cause mild pain and be
managed by ambulation, showers, and rest.
Choice C rationale
Chorioamnionitis is an infection of the fetal membranes and amniotic fluid, leading to fever, uterine tenderness, and foul-smelling amniotic fluid, not mild contractions and moderate
variability in FHR.
Choice D rationale
Iron deficiency anemia in pregnancy can cause fatigue, pallor, and shortness of breath but does not affect uterine contractions or fetal heart rate.
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Correct Answer is A
Explanation
Choice A rationale
A newborn who is 26 hours post-delivery and has had no urine output needs immediate attention. Lack of urine output for over 24 hours may indicate dehydration or renal issues. Immediate medical evaluation is required to identify underlying conditions and prevent complications such as acute kidney injury or sepsis.
Choice B rationale
Acrocyanosis, characterized by blueish discoloration of the extremities, is common in newborns during the first 24-48 hours of life and usually resolves on its own. It occurs due to immature blood circulation and is generally not a cause for concern.
Choice C rationale
Failure to pass meconium within the first 24 hours can be a sign of conditions like Hirschsprung's disease or cystic fibrosis, but it is not as immediately concerning as anuria (no urine output). Monitoring and further evaluation are necessary, but it does not require urgent provider notification.
Choice D rationale
A blood glucose level of 50 mg/dL in a newborn is within the lower limit of normal. While it's important to monitor, it does not necessitate immediate provider notification unless it continues to drop or other symptoms arise.
Correct Answer is ["A","B","C","D","G"]
Explanation
Choice A: Respiratory assessment
The newborn is exhibiting signs of respiratory distress, such as mild grunting, nasal flaring, and intermittent retractions. These symptoms indicate potential respiratory issues that need immediate attention.
Choice B: Hemoglobin
The newborn's hemoglobin level is 9 g/dL, which is below the normal range of 14 to 24 g/dL2. This indicates anemia, which can affect the baby's oxygen-carrying capacity and overall health.
Choice C: Serum glucose
The newborn's serum glucose level is 38 mg/dL, which is below the normal range of 40 to 45 mg/dL2. Hypoglycemia in newborns can lead to serious complications if not addressed promptly.
Choice D: Heart rate
The newborn's heart rate is 180 beats per minute, which is above the normal range for a newborn (normal range: 120-160 beats per minute)2. This tachycardia could be a response to stress or an underlying condition that needs evaluation.
Choice G: Hematocrit
The newborn's hematocrit level is 35%, which is below the normal range of 44% to 64%2. This further supports the presence of anemia and the need for intervention2