Nokea
A client at 41-weeks gestation is admitted to the labor and delivery unit for induction of labor. The client's cervix is dilated 2 cm, 50% effaced, and the fetus is at -2 station. The Bishop score is 4. What action should the nurse anticipate?
- A. Administration of prostaglandin gel.
- B. Rupture of membranes.
- C. Administration of oxytocin.
- D. Preparation for a cesarean section.
Correct Answer: A
Rationale: A Bishop score of 4 indicates an unfavorable cervix, and prostaglandin gel is typically used to ripen the cervix before induction.
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Which clinical finding is associated with inadequate maternal weight gain during pregnancy?
- A. Prolonged labor
- B. Preeclampsia
- C. Gestational diabetes
- D. Low-birth-weight infant
Correct Answer: D
Rationale: The correct answer is D: Low-birth-weight infant. Inadequate maternal weight gain during pregnancy is associated with an increased risk of delivering a low-birth-weight infant due to insufficient fetal growth and development. When a mother does not gain enough weight during pregnancy, it can result in the baby being born smaller than expected, which can lead to various health issues. Prolonged labor (choice A) is not directly linked to inadequate weight gain. Preeclampsia (choice B) and gestational diabetes (choice C) are more commonly associated with excessive weight gain or other factors. Therefore, the correct choice is D as it directly correlates with inadequate maternal weight gain.
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.
The nurse is writing an expected outcome for the nursing diagnosis—acute pain related to tissue trauma, secondary to vaginal birth, as evidenced by patient stating pain of 8 on a scale of 10. Which expected outcome is correctly stated for this problem?
- A. Patient will state that pain is a 2 on a scale of 10.
- B. Patient will have a reduction in pain after administration of the prescribed analgesic.
- C. Patient will state an absence of pain 1 hour after administration of the prescribed analgesic.
- D. Patient will state that pain is a 2 on a scale of 10, 1 hour after the administration of the prescribed analgesic.
Correct Answer: D
Rationale: The outcome should be patient-centered, measurable, realistic, and attainable within a specified timeframe.
The nurse should encourage the laboring client to begin pushing when
- A. There is only an anterior or posterior lip of cervix left
- B. The client describes the need to have a bowel movement
- C. The cervix is completely dilated
- D. The cervix is completely effaced
Correct Answer: C
Rationale: Pushing begins with the second stage of labor, i.e., when the cervix is completely dilated (C), the cervix can become edematous and may never completely dilate, necessitating an operative delivery. Many primigravidas begin active labor 100% effaced and then proceed to dilate.
Which nursing intervention is an independent function of the professional nurse?
- A. Administering oral analgesics
- B. Requesting diagnostic studies
- C. Teaching the patient perineal care
- D. Providing wound care to a surgical incision
Correct Answer: C
Rationale: Teaching is an independent nursing function, whereas administering medications or requesting diagnostic studies are dependent functions requiring physician orders.