A client in active labor reports back pain while being examined by a nurse who finds her to be 8 cm dilated, 100% effaced, -2 station, and in the occiput posterior position. What action should the nurse take?
- A. Perform effleurage during contractions.
- B. Place the client in lithotomy position.
- C. Assist the client to the hands and knees position.
- D. Apply a scalp electrode to the fetus.
Correct Answer: C
Rationale: The correct action is to assist the client to the hands and knees position. This position, also known as the all-fours position, can help alleviate back pain by encouraging the baby to rotate into a more favorable position for delivery. By being on hands and knees, gravity assists in the rotation of the baby. This position can also help relieve pressure on the mother's back and potentially facilitate a smoother labor progress. Effleurage (choice A) may provide comfort but doesn't address the positional issue. Placing the client in lithotomy position (choice B) can worsen the occiput posterior position. Applying a scalp electrode to the fetus (choice D) is not indicated in this scenario.
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A nurse in the emergency department is caring for a client who reports abrupt, sharp, right-sided lower quadrant abdominal pain and bright red vaginal bleeding. The client states, 'I missed one menstrual cycle and cannot be pregnant because I have an intrauterine device.' The nurse should suspect which of the following?
- A. Missed abortion
- B. Ectopic pregnancy
- C. Severe preeclampsia
- D. Hydatidiform mole
Correct Answer: B
Rationale: The correct answer is B: Ectopic pregnancy. Given the client's symptoms of right-sided lower quadrant abdominal pain, vaginal bleeding, missed menstrual cycle, and presence of an intrauterine device, these are classic signs of an ectopic pregnancy. Ectopic pregnancy occurs when a fertilized egg implants outside the uterus, commonly in the fallopian tube, leading to abdominal pain and vaginal bleeding. The other choices are incorrect because:
A: Missed abortion would typically present with cramping, bleeding, and passage of tissue.
C: Severe preeclampsia is characterized by high blood pressure and proteinuria, not the symptoms described.
D: Hydatidiform mole would typically present with vaginal bleeding and uterine enlargement, but not the sharp abdominal pain described.
A client in a prenatal clinic is receiving education from a nurse and mentions, 'I don't like milk.' Which of the following foods should the nurse recommend as a good source of calcium?
- A. Dark green leafy vegetables
- B. Deep red or orange vegetables
- C. White bread and rice
- D. Meat, poultry, and fish
Correct Answer: A
Rationale: The correct answer is A: Dark green leafy vegetables. Dark green leafy vegetables like kale, spinach, and broccoli are excellent sources of calcium. They provide a good alternative to dairy for those who don't like milk. These vegetables are rich in calcium, which is essential for bone health, especially during pregnancy. They also offer other nutrients like vitamin K and magnesium that support calcium absorption.
Summary:
B: Deep red or orange vegetables - While these vegetables are nutritious, they are not significant sources of calcium.
C: White bread and rice - These foods do not provide a significant amount of calcium.
D: Meat, poultry, and fish - While these foods are rich in protein and other nutrients, they are not primary sources of calcium.
A client presents with uterine hypotonicity and postpartum hemorrhage. Which action should the nurse prioritize?
- A. Check the client's capillary refill.
- B. Massage the client's fundus.
- C. Insert an indwelling urinary catheter for the client.
- D. Prepare the client for a blood transfusion.
Correct Answer: B
Rationale: Rationale: Massaging the client's fundus helps to stimulate uterine contractions and control postpartum hemorrhage caused by uterine hypotonicity. This action helps prevent further blood loss and promotes uterine tone. Checking capillary refill would not directly address the immediate issue of hemorrhage. Inserting a urinary catheter is not a priority in managing postpartum hemorrhage. Preparing for a blood transfusion may be necessary later, but addressing the uterine hypotonicity and hemorrhage is the priority.
During a teaching session with a client in labor, a nurse is explaining episiotomy. Which of the following information should the nurse include?
- A. An episiotomy is a perineal incision made by the provider to facilitate delivery of the fetus
- B. A fourth-degree episiotomy extends into the rectal area and is not recommended
- C. An episiotomy is an incision made by the provider to facilitate delivery of the fetus
- D. A mediolateral episiotomy is preferred over a median episiotomy for most deliveries
Correct Answer: C
Rationale: The correct answer is C because it accurately describes an episiotomy as an incision made by the provider to facilitate delivery of the fetus. This information is crucial for the client to understand the purpose and potential benefits of the procedure.
A: While choice A is similar to the correct answer, it includes unnecessary detail about who makes the incision, which may confuse the client.
B: Choice B is incorrect as it provides inaccurate information about a fourth-degree episiotomy extending into the rectal area, which is not recommended as it would involve cutting through the anal sphincter.
D: Choice D is incorrect because it introduces unnecessary information about the types of episiotomies without providing the basic understanding of what an episiotomy is.
A client in active labor at 39 weeks of gestation is receiving continuous IV oxytocin and has early decelerations in the FHR on the monitor tracing. What action should the nurse take?
- A. Discontinue the oxytocin infusion.
- B. Continue monitoring the client.
- C. Request that the provider assess the client.
- D. Increase the infusion rate of the maintenance IV fluid.
Correct Answer: B
Rationale: The correct action for the nurse to take when a client in active labor at 39 weeks of gestation has early decelerations in the FHR on the monitor tracing is to continue monitoring the client. Early decelerations are typically benign and are associated with head compression during contractions, which is a normal response to labor. There is no need to discontinue the oxytocin infusion as early decelerations do not indicate fetal distress. Requesting the provider to assess the client may not be necessary at this point unless other concerning signs are present. Increasing the infusion rate of the maintenance IV fluid is not indicated as it would not address the early decelerations. Therefore, the best course of action is to continue monitoring the client for any changes in the FHR pattern.