1053) The nurse in a labor room is monitoring a client with dysfunctional labor for signs of fetal or maternal compromise. Which assessment finding would alert the nurse to a compromise?
1. Maternal fatigue
2. Coordinated uterine contractions
3. Progressive changes in the cervix
4. Persistent nonreassuring fetal heart rate
Answer:4. Signs of fetal or maternal compromise include a persistent, nonreassuring fetal heart rate, fetal acidosis, and the passage of meconium. Maternal fatigue and infection can occur if the labor is prolonged, but do not indicate fetal or maternal compromise. Progressive changes in the cervix and coordinated uterine contractions are a reassuring pattern in labor.
1054) The nurse is performing an initial assessment on a newborn infant. When assessing the infant's head, the nurse notes that the ears are low-set. Which nursing action is most appropriate?
1. Document the findings.
2. Arrange for hearing testing.
3. Notify the health care provider.
4. Cover the ears with gauze pads.
Answer:3. Low or oddly placed ears are associated with various congenital defects and should be reported immediately. Although the findings should be documented, the most appropriate action would be to notify the health care provider. Options 2 and 4 are inaccurate and inappropriate nursing actions.
1055) A nurse is caring for a pregnant woman who has herpes genitalis. The nurse provides instructions to the woman about treatment modalities that may be necessary for this condition. Which statement made by the woman indicates an understanding of these treatment measures?
1. "I do not need to abstain from sexual intercourse."
2. "I need to use vaginal creams after I douche every day."
3. "I need to douche and perform a sitz bath three times a day."
4. "It may be necessary to have a cesarean section for delivery."
Answer:4. If a woman has an active lesion, either recurrent or primary at the time of labor, delivery should be by cesarean. Women are advised to abstain from sexual contact while the lesions are present. If it is an initial infection, the woman should continue to abstain from sexual intercourse until the cultures are negative because prolonged viral shedding may occur. Douches are contraindicated, and the genital area should be kept clean and dry to promote healing.