Nokea
The nurse is evaluating the client in triage for possible labor. The client’s contractions are every 3 to 4 minutes, 60 to 70 seconds in duration, and moderate by palpation. Her cervical exam in the office was illustration 1. Her current exam is illustration 2. What conclusions should the nurse draw from illustration 2?
- A. The client is not dilated or effaced.
- B. The client is completely dilated but not effaced.
- C. The client has minimally dilated, but completely effaced.
- D. The client is not dilated, but completely effaced.
Correct Answer: C
Rationale: In illustration 2, the client is completely effaced and has some dilation. Illustration 1 (not illustration 2) shows that the client is neither effaced nor dilated. The cervical opening is minimally dilated, not completely dilated, and completely effaced. Illustration 2 shows some dilation.
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The nurse is evaluating the 39-weeks-pregnant client who reports greenish, foul-smelling vaginal discharge. Her temperature is 101.6°F (38.7°C), and the FHR is 120 with minimal variability and no accelerations. The client’s group beta streptococcus (GBS) culture is positive. Which interventions should the nurse plan to implement? Select all that apply.
- A. Prepare for cesarean birth due to chorioamnionitis
- B. Start oxytocin for labor induction
- C. Start antibiotics as directed for the GBS infection
- D. Prepare the client for epidural anesthesia
- E. Notify the neonatologist of the client’s status
- F. Administer a cervical ripening agent
Correct Answer: A,C,D,E
Rationale: Because this client is not in labor and chorioamnionitis is possible, a cesarean birth is indicated. The client should be given antibiotics as prescribed to treat the infection. Because epidural anesthesia offers the least risk to the fetus, preparation for epidural anesthesia should begin. The pediatrician or neonatologist should be notified and available for the impending delivery. Starting oxytocin (Pitocin) would prolong the time to delivery. Administering a cervical ripening agent would prolong the time to delivery.
Which screening is recommended for a client over 35 years old?
- A. Amniocentesis for genetic disorders
- B. Blood type screening
- C. Urine culture
- D. Basic ultrasound
Correct Answer: A
Rationale: Amniocentesis is recommended for women over 35 to screen for genetic disorders due to increased risk with advanced maternal age.
The nurse is teaching the client who is wishing to travel by airplane during the first 36 weeks of her pregnancy. Which is the primary risk of air travel for this client that the nurse should address?
- A. Risk of preterm labor
- B. Deep vein thrombosis
- C. Spontaneous abortion
- D. Nausea and vomiting
Correct Answer: B
Rationale: The primary risk with air travel during pregnancy is DVT. Pregnancy increases the risk of blood coagulation, and prolonged sitting produces venous stasis. Preterm labor is not associated with air travel. The threat of spontaneous abortion diminishes during the second trimester. Spontaneous abortion is not associated with air travel. Although nausea and vomiting can occur, they are not dangerous.
At this point in the client's pregnancy, which test is typically used to detect genetic disorders?
- A. Amniocentesis
- B. Chorionic villi sampling
- C. Rapid plasma reagin
- D. Ultrasound
Correct Answer: B
Rationale: Chorionic villi sampling is performed at 10-13 weeks to detect genetic disorders, suitable for a 10-week pregnancy.
Which safety measure should the nurse emphasize for newborn sleep?
- A. Place the newborn on their back to sleep
- B. Use soft bedding for comfort
- C. Co-sleep in the parent's bed
- D. Keep the room very warm
Correct Answer: A
Rationale: Placing the newborn on their back to sleep reduces the risk of sudden infant death syndrome (SIDS).