1050) The nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which is noted on the external monitor tracing during a contraction?
3. Early decelerations
4. Early decelerations
Answer:4. Variable decelerations occur if the umbilical cord becomes compressed, reducing blood flow between the placenta and the fetus. Variability refers to fluctuations in the baseline fetal heart rate. Accelerations are a reassuring sign and usually occur with fetal movement. Early decelerations result from pressure on the fetal head during a contraction.
1051) The nurse in the gynecology clinic is reviewing the record of a pregnant client after the first prenatal visit. The nurse notes that the health care provider has documented that the woman has a platypelloid pelvis. On the basis of this documentation, the nurse plans care, knowing that this type of pelvis has which characteristic?
1. Is heart-shaped
2. Has a flat shape
3. Has an oval shape
4. Is a normal female pelvis
Answer:2. A platypelloid pelvis has a flat shape. An anthropoid pelvis has an oval shape, and an android pelvis is heart-shaped. A gynecoid pelvis is a normal female pelvis.
1052) The nurse is assessing the deep tendon reflexes of a client with severe preeclampsia who is receiving intravenous magnesium sulfate. The nurse should perform which procedure to assess the brachioradialis reflex? Refer to Figure.
Answer:1. To assess the brachioradialis reflex, the client's thumb is held to suspend the forearm in relaxation. The nurse then strikes the forearm directly, about 2 to 3 cm above the radial styloid process. The normal response is flexion and supination of the forearm. Option 2 identifies the procedure for assessing the quadriceps reflex. Option 3 identifies the procedure for assessing the biceps reflex. Option 4 identifies the procedure for assessing the triceps reflex.