Nokea
A 21-year-old primigravid client at 40 weeks' gestation is admitted to the hospital in active labor. The client's cervix is 8 cm and completely effaced at 0 station. During the transition phase of labor, which of the following is a priority nursing diagnosis?
- A. Impaired urinary elimination related to nothing-by-mouth status.
- B. Risk for injury related to hyperventilation and dizziness.
- C. Ineffective coping related to lack of confidence.
- D. Pain related to increasing frequency and intensity of uterine contractions.
Correct Answer: D
Rationale: During the transition phase (8–10 cm), intense and frequent contractions cause significant pain, making pain management the priority nursing diagnosis. Urinary elimination issues are less urgent, hyperventilation is a secondary concern, and coping issues are not as immediate as pain.
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A nurse is counseling a client about the use of a vaginal contraceptive ring. Which of the following client statements indicates understanding?
- A. I should remove the ring every night before bed.
- B. The ring is left in place for three weeks, then removed for one week.
- C. I need to replace the ring every two weeks.
- D. The ring protects against HIV transmission.
Correct Answer: B
Rationale: The vaginal contraceptive ring is left in place for three weeks, then removed for one week to allow a withdrawal bleed. It is not removed nightly, replaced every two weeks, or protective against HIV.
The physician orders 1000 mL of Ringer's Lactate intravenously over an 8-hour period for a 29-year-old primigravid client at 16 weeks' gestation with hyperemesis. The drip factor is 12 gtts/mL. The nurse should administer the IV infusion at how many drops per minute?
- A. 25 gtts/minute.
- B. 30 gtts/minute.
- C. 35 gtts/minute.
- D. 40 gtts/minute.
Correct Answer: A
Rationale: Calculation: (1000 mL * 12 gtts/mL) / (8 hours * 60 minutes) = 25 gtts/minute.
Which of the following instructions should the nurse give to the parents of a neonate diagnosed with hyperbilirubinemia who is receiving phototherapy?
- A. Keep the neonate's eyes completely covered.
- B. Use a regular diaper on the neonate.
- C. Offer feedings every 4 hours.
- D. Check the oral temperature every 8 hours.
Correct Answer: A
Rationale: Keeping the neonate's eyes completely covered protects them from potential retinal damage during phototherapy.
A neonate delivered at 40 weeks' gestation admitted to the nursery is found to be hypoglycemic. At 4 hours of age, the neonate appears pale and his pulse oximeter is reading 75 %. The nurse should:
- A. Increase the I.V. rate.
- B. Provide supplemental oxygen.
- C. Record the finding on the chart and repeat the reading in 30 minutes.
- D. Wrap the neonate to increase body temperature.
Correct Answer: B
Rationale: A pulse oximetry reading of 75% indicates hypoxemia, and providing supplemental oxygen is the priority.
Which of the following actions should the nurse take when performing external cardiac massage on a neonate born at 28 weeks' gestation?
- A. Alternate cardiac massage with ventilation.
- B. Compress the sternum with the palm of the hand.
- C. Compress the chest 70 to 80 times per minute.
- D. Displace the chest 70 to 80 times per minute.
Correct Answer: A
Rationale: Alternating cardiac massage with ventilation follows neonatal resuscitation guidelines to restore circulation and oxygenation.