1. The nurse is caring for a client admitted to labor and delivery. The nurse is aware that the infant is in distress if she notes:
A. Contractions every three minutes
B. Absent variability
C. Fetal heart tone accelerations with movement
D. Fetal heart tone 120–130bpm
Answer B is correct. Absent variability is not normal and could indicate a neurological problem. Answers A, C, and D are normal findings. 246. Answer D is correct. Clients admitted in labor are told not to eat during labor, to avoid nausea and vomiting. Ice chips might be allowed, although this amount of fluid might not be sufficient to prevent fluid volume deficit. In answer A, impaired gas exchange related to hyperventilation would be indicated during the transition phase, not the early phase of labor. Answers B and C are not correct because clients during labor are allowed to change position as she desires.
2. The nurse is providing dietary instructions to the mother of an 8-year-old child diagnosed with celiac disease. Which of the following foods, if selected by the mother, would indicate her understanding of the dietary instructions?
A. Cheese omelet
B. Whole-wheat bread
C. Hamburger on wheat bun with ketchup