Nokea
A 19-year-old primigravid client at 38 weeks' gestation is admitted to the hospital in active labor that began 8 hours ago. When the client's cervix is 7 cm dilated and the presenting part is at +1 station, the client tells the nurse, 'I need to push!' Which of the following would the nurse do next?
- A. Use the McDonald procedure to widen the pelvic opening.
- B. Increase the rate of oxygen and intravenous fluids.
- C. Tell the client to use a pant-blow pattern of breathing.
- D. Tell the client to push only when absolutely necessary.
Correct Answer: C
Rationale: At 7 cm dilation, the client is not fully dilated, and pushing can cause cervical trauma. A pant-blow breathing pattern helps manage the urge to push until full dilation. The McDonald procedure is for cervical cerclage, and increasing oxygen/fluids or encouraging pushing is inappropriate.
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A preterm neonate who has been stabilized is placed in a radiant warmer and is receiving oxygen via an oxygen hood. While administering oxygen in this manner, the nurse should do which of the following?
- A. Humidify the air being delivered.
- B. Cover the neonate's scalp with a warm cap.
- C. Record the neonate's temperature every 3 to 4 minutes.
- D. Assess the neonate's blood glucose level.
Correct Answer: A
Rationale: Humidifying the air prevents drying of the mucous membranes and maintains airway moisture, which is critical for preterm neonates.
A nurse is discussing the contraceptive patch with a client. Which of the following side effects should the nurse mention?
- A. Nausea and skin irritation at the application site.
- B. Permanent hair loss.
- C. Guaranteed weight loss.
- D. Increased risk of ovarian cysts.
Correct Answer: A
Rationale: The contraceptive patch may cause nausea and skin irritation at the application site, especially initially. It does not cause permanent hair loss, guarantee weight loss, or significantly increase ovarian cyst risk.
Four hours after cesarean delivery of a neonate weighing 4,000 g (8 lb, 13 oz), the primiparous client asks, "If I get pregnant again, will I need to have a cesarean?" When responding to the client, the nurse should base the response to the client about vaginal birth after cesarean delivery (VBAC) on which of the following?
- A. VBAC may be possible if the client has not had a classic uterine incision.
- B. A history of rapid labor is a necessary criterion for VBAC.
- C. A low transverse incision contraindicates the possibility for VBAC.
- D. VBAC is not possible because the neonate was large for gestational age.
Correct Answer: A
Rationale: VBAC is often possible with a low transverse incision, unlike a classic vertical incision.
A couple is inquiring about vasectomy as a permanent method of contraception. Which teaching statement would the nurse include in the teaching plan?
- A. Another method of contraception is needed until the sperm count is 0.
- B. Vasectomy is easily reversed if children are desired in the future.
- C. Vasectomy is contraindicated in males with prior history of cardiac disease.
- D. Vasectomy requires only a yearly follow-up once the procedure is completed.
Correct Answer: A
Rationale: After a vasectomy, another contraception method is needed until a follow-up semen analysis confirms a zero sperm count, ensuring sterility.
A client at 28 weeks' gestation in premature labor was placed on ritodrine(Yutopar). To maintain the pregnancy, the physician orders the client to have 10 mg now, 10 mg in 2 hours, and then 20 mg every 4 hours while contractions persist, not to exceed the maximum daily oral dose of 120 mg. At what time will the client have reached the maximum dose if she begins taking the medication at 10:00 a.m. and follows the physician's order?
- A. 10:00 a.m.
- B. 10:00 p.m.
- C. 12:00 a.m.
- D. 2:00 a.m.
Correct Answer: B
Rationale: The client will reach the maximum dose at 10:00 p.m.