Nokea
A client at 40 weeks of gestation is experiencing contractions every 3 to 5 minutes, becoming stronger. A vaginal exam by the registered nurse reveals the client's cervix is 3 cm dilated, 80% effaced, and -1 station. The client requests pain medication. Which of the following actions should the nurse prepare to take? (Select all that apply)
- A. Provide ice chips.
- B. Insert an indwelling urinary catheter.
- C. Administer opioid analgesic medication.
- D. Provide ice chips.
Correct Answer: C
Rationale: The correct action is to administer opioid analgesic medication (Choice C). At 40 weeks gestation with contractions every 3-5 minutes, 3 cm dilated, 80% effaced, and -1 station, the client is in active labor. Pain medication is appropriate to manage discomfort during labor. Opioid analgesics can help reduce pain intensity while still allowing the client to remain alert and participate in labor. Ice chips (Choice A and D) are not directly related to pain management in labor. Inserting a urinary catheter (Choice B) is not indicated unless there are specific concerns about bladder distention.
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When providing care for a client in preterm labor at 32 weeks of gestation, which medication should the nurse anticipate the provider will prescribe to hasten fetal lung maturity?
- A. Calcium gluconate
- B. Indomethacin
- C. Nifedipine
- D. Betamethasone
Correct Answer: D
Rationale: Step 1: Betamethasone is a corticosteroid that promotes fetal lung maturity by stimulating the production of surfactant, essential for lung function.
Step 2: At 32 weeks, the fetus may benefit from accelerated lung development to reduce respiratory distress.
Step 3: Calcium gluconate is used for hypocalcemia, not for fetal lung maturity.
Step 4: Indomethacin is a nonsteroidal anti-inflammatory drug used to delay preterm labor, not for lung maturity.
Step 5: Nifedipine is a calcium channel blocker to prevent preterm labor, not for fetal lung maturity.
A healthcare provider is reviewing the health record of a client who is pregnant. The provider indicated the client exhibits probable signs of pregnancy. Which of the following findings should the provider expect? (Select all that apply)
- A. Chadwick's sign
- B. Goodell's sign
- C. Ballottement
- D. All of the above
Correct Answer: D
Rationale: The correct answer is D because all three signs (Chadwick's sign, Goodell's sign, and Ballottement) are probable signs of pregnancy. Chadwick's sign refers to bluish discoloration of the cervix, Goodell's sign is softening of the cervix, and Ballottement is a palpable rebound of the fetus against the examiner's fingers. These signs are indicative of pregnancy and are commonly observed in pregnant individuals. Therefore, the provider should expect to see all these findings in a pregnant client. The other choices (A, B, and C) are incorrect because each of these signs individually is a probable sign of pregnancy, and the question asks for all the expected findings, not just one or two of them.
During an assessment, a client at 26 weeks of gestation presents with which of the following clinical manifestations that should be reported to the provider?
- A. Leukorrhea
- B. Supine hypotension
- C. Periodic numbness of the fingers
- D. Decreased urine output
Correct Answer: D
Rationale: The correct answer is D: Decreased urine output. At 26 weeks of gestation, decreased urine output can be a sign of potential complications like preeclampsia or dehydration, which require immediate medical attention to prevent harm to the mother and baby. Leukorrhea (choice A) is a common pregnancy symptom and not typically concerning. Supine hypotension (choice B) is a known issue in pregnancy but usually occurs later in the third trimester due to pressure on the vena cava when lying on the back. Periodic numbness of the fingers (choice C) can be related to carpal tunnel syndrome, which is common in pregnancy but not typically urgent at 26 weeks unless severe and persistent.
What is the most appropriate statement for a nurse to make to a client who has recently experienced a perinatal death?
- A. It must be a comfort to know you have another child.
- B. I'm sad for you.
- C. There is usually something wrong with the baby.
- D. You will always have an angel in heaven.
Correct Answer: B
Rationale: The correct answer is B: "I'm sad for you." This response shows empathy and acknowledges the client's feelings without making assumptions or providing false reassurance. It validates the client's emotions and offers support.
Incorrect choices:
A: This statement assumes the client's feelings and may not be comforting.
C: This statement is insensitive and can cause unnecessary guilt or blame.
D: While well-intentioned, this statement may not align with the client's beliefs and can be dismissive of their grief.
When caring for a client in labor, which of the following infections can be treated during labor or immediately following birth? (Select all that apply)
- A. Gonorrhea
- B. Chlamydia
- C. HIV
- D. All of the Above
Correct Answer: D
Rationale: The correct answer is D: All of the Above. All three infections - Gonorrhea, Chlamydia, and HIV - can be treated during labor or immediately following birth to prevent transmission to the newborn. Antibiotics can be administered for Gonorrhea and Chlamydia, while antiretroviral medications can be given for HIV. Prompt treatment is crucial to reduce the risk of vertical transmission. The other choices are incorrect because each infection listed can be effectively managed during labor or post-birth, making choice D the most comprehensive and accurate option.