The nurse is assessing a primigravida at 39 weeks gestation during a weekly prenatal visit. Which finding is most important for the nurse to report to the healthcare provider (HCP)?
Reference Range:Hemoglobin in pregnancy [greater than 11 g/dL (110 g/L)]

Troubled by early morning heartburn.

Fetal heart rate (FHR) of 200 beats/minute.

Maternal hemoglobin of 11.0 g/dL (110 g/L).

Reports intermittent low back pain.

Answer and Explanation

The Correct Answer is B

Rationale:

A. Troubled by early morning heartburn: Heartburn is common in late pregnancy due to hormonal changes and pressure from the uterus. While uncomfortable, it is not an urgent concern and does not require immediate reporting.

B. Fetal heart rate (FHR) of 200 beats/minute: A FHR of 200 bpm is significantly above the normal range (110–160 bpm) and may indicate fetal tachycardia, which can result from infection, maternal fever, or fetal distress. This requires immediate notification of the HCP.

C. Maternal hemoglobin of 11.0 g/dL (110 g/L): This value is within the normal range for pregnancy and does not indicate anemia or require urgent intervention.

D. Reports intermittent low back pain: Mild low back pain is common in late pregnancy due to postural changes and increased lumbar lordosis. While symptomatic relief may be needed, it is not an urgent finding requiring immediate HCP notification.

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Correct Answer is D

Explanation

Rationale:

A. Document the finding in the infant's record: Documentation is necessary for all assessment findings, but an irregular heart rate in a newborn may indicate a potentially serious cardiac issue. Simply recording it without notifying the healthcare provider could delay critical evaluation or intervention.

B. Teach the parents about congenital heart defects: Parental education is important, but it is not the immediate priority when a newborn has an irregular heart rate. Immediate assessment and guidance from a healthcare provider take precedence over education.

C. Apply oxygen per nasal cannula at 3 L/min: Administering oxygen is only indicated if the infant shows signs of hypoxia or respiratory distress. An irregular heart rate alone does not automatically require supplemental oxygen without further assessment.

D. Notify the pediatrician immediately: Immediate notification of the pediatrician is essential because an irregular heart rate may signal arrhythmias, congenital heart defects, or other serious cardiac conditions. Prompt evaluation ensures timely intervention to prevent complications.

A. Contact the healthcare provider. B. Assess the fetal heart rate (FHR). C. Check the cervical dilation. D. Turn the client to her left side.

Correct Answer is B

Explanation

Rationale:

A. Contact the healthcare provider: Notifying the provider is important if meconium-stained fluid is present, but immediate assessment of fetal well-being takes priority before contacting the provider.

B. Assess the fetal heart rate (FHR): The presence of greenish-brown amniotic fluid indicates possible meconium-stained fluid, which can signal fetal distress. Assessing the FHR first allows the nurse to determine if the fetus is currently compromised and requires urgent intervention.

C. Check the cervical dilation: Cervical assessment provides information about labor progression but does not address the immediate concern of potential fetal compromise from meconium aspiration.

D. Turn the client to her left side: Positioning can improve uteroplacental perfusion if the fetus is distressed, but the first step is to assess the FHR to identify any current compromise before implementing interventions.

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The nurse is assessing a primigravida at 39 weeks gestation during a weekly prenatal visit. Which finding is most important for the nurse to report to the healthcare provider (HCP)? Reference Range:Hemoglobin in pregnancy [greater than 11 g/dL (110 g/L)]

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During the initial newborn assessment, the nurse finds that a newborn's heart rate is irregular. Which intervention should the nurse implement?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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The nurse is assessing a primigravida at 39 weeks gestation during a weekly prenatal visit. Which finding is most important for the nurse to report to the healthcare provider (HCP)?
Reference Range:Hemoglobin in pregnancy [greater than 11 g/dL (110 g/L)]