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A client at 38-weeks gestation is admitted to the labor and delivery unit with mild contractions every 5 minutes. The client's cervix is dilated 2 cm, 50% effaced, and the fetus is at 0 station. The client's membranes rupture spontaneously, and the fluid is clear. What action should the nurse take next?
- A. Monitor the fetal heart rate pattern.
- B. Perform a vaginal examination.
- C. Encourage the client to ambulate.
- D. Administer pain medication.
Correct Answer: A
Rationale: Monitoring the fetal heart rate pattern after membrane rupture is essential to detect any changes in fetal status.
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Which patient has correctly increased her caloric intake from her recommended pregnancy intake to the amount necessary to sustain breastfeeding in the first 6 postpartum months?
- A. From 1800 to 2200 calories per day
- B. From 2000 to 2500 calories per day
- C. From 2200 to 2530 calories per day
- D. From 2500 to 2730 calories per day
Correct Answer: C
Rationale: Rationale: The correct answer is C because for breastfeeding, an additional 500 calories/day are needed compared to pregnancy. The recommended caloric intake during pregnancy is around 2200 calories/day. Therefore, increasing from 2200 to 2530 calories/day aligns with the additional 500 calories necessary for sustaining breastfeeding.
Summary:
A: Going from 1800 to 2200 calories/day does not provide the extra 500 calories needed for breastfeeding.
B: Increasing from 2000 to 2500 calories/day does not account for the original pregnancy intake or the additional calories required for breastfeeding.
D: Jumping from 2500 to 2730 calories/day exceeds the additional 500 calories needed for breastfeeding, potentially leading to excessive weight gain.
The nurses assessing a 38-week gestation newborn infant immediately following a vaginal birth. Which assessment finding best indication that the infant is transitioning well to extrauterine life?
- A. Heart rate 220 beats/minute
- B. Cries vigorously when stimulated
- C. A positive Babinski reflex
- D. Flexion of all four extremities
Correct Answer: B
Rationale: Vigorous crying (B) indicates effective transition to extrauterine life.
A client at 39-weeks gestation is admitted to the labor and delivery unit in active labor. The client's cervix is dilated 7 cm, 100% effaced, and the fetus is at +1 station. The client begins to push forcefully with contractions. What action should the nurse take?
- A. Encourage the client to pant-blow during contractions.
- B. Assist the client to push with contractions.
- C. Prepare for an immediate delivery.
- D. Notify the healthcare provider.
Correct Answer: A
Rationale: Pant-blow breathing helps prevent premature pushing before full dilation, reducing the risk of cervical edema.
A client who is anovulatory and has hyperprolactinemia is being treated for infertility with metformin, menotropins (Repronex, MENOPUR®), and human chorionic gonadotropin(hCG). Which side effects should the nurse tell the client to report immediately?
- A. Episodes of headache and irritability
- B. Nausea and vomiting
- C. Rapid increase in abdominal girth
- D. Persistent daytime fatigue
Correct Answer: C
Rationale: Rapid abdominal girth increase (C) may indicate ovarian hyperstimulation syndrome, a serious complication.
A pregnant, homeless woman who has received no prenatal care presents to the clinic in her third trimester because she is having vaginal bleeding but reports that she is not in pain. Ultrasound reveals a placenta previa. Which actions should the nurse implement?
- A. Schedule weekly prenatal appointments
- B. Contact social services for a temporary shelter
- C. Obtain a hemoglobin and hematocrit level
- D. Have the client transported to the hospital
Correct Answer: D
Rationale: Placenta previa requires hospitalization to monitor for bleeding (D).