Nokea
A client in labor requests epidural anesthesia for pain control. Which of the following actions should the nurse include in the plan of care?
- A. Position the client supine for 30 minutes after the first dose of anesthetic solution.
- B. Administer 1,000 mL of dextrose 5% in water after the first dose of anesthetic solution.
- C. Monitor the client's blood pressure every 5 minutes after the first dose of anesthetic solution.
- D. Ensure the client has been NPO for 4 hours before the placement of the epidural and the first dose of anesthetic solution.
Correct Answer: C
Rationale: The correct answer is C: Monitor the client's blood pressure every 5 minutes after the first dose of anesthetic solution. This is crucial as epidural anesthesia can cause hypotension, which can lead to maternal and fetal complications. Monitoring blood pressure every 5 minutes allows for early detection and intervention.
A: Positioning the client supine for 30 minutes after the first dose of anesthetic solution can lead to hypotension due to decreased venous return, so this is incorrect.
B: Administering dextrose 5% in water is not a standard practice after epidural anesthesia and does not address the risk of hypotension, so this is incorrect.
D: Ensuring the client has been NPO for 4 hours before the procedure is important for general anesthesia but not specifically for epidural anesthesia, so this is incorrect.
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A client in active labor is irritable, reports the urge to have a bowel movement, vomits, and states, 'I've had enough. I can't do this anymore.' Which of the following stages of labor is the client experiencing?
- A. Second stage
- B. Fourth stage
- C. Transition phase
- D. Latent phase
Correct Answer: C
Rationale: The client is experiencing the transition phase of labor. This stage occurs between the first and second stages, characterized by intense contractions, rapid cervical dilation, and strong emotions like irritability and feeling overwhelmed. The urge to have a bowel movement and vomiting are common signs indicating the baby is descending. The statement 'I can't do this anymore' is typical of transition as it signifies the peak of discomfort before the urge to push in the second stage. Other options are incorrect as the symptoms described align with the transition phase.
A client in a prenatal clinic is receiving education from a nurse and mentions, 'I don't like milk.' Which of the following foods should the nurse recommend as a good source of calcium?
- A. Dark green leafy vegetables
- B. Deep red or orange vegetables
- C. White bread and rice
- D. Meat, poultry, and fish
Correct Answer: A
Rationale: The correct answer is A: Dark green leafy vegetables. Dark green leafy vegetables like kale, spinach, and broccoli are excellent sources of calcium. They provide a good alternative to dairy for those who don't like milk. These vegetables are rich in calcium, which is essential for bone health, especially during pregnancy. They also offer other nutrients like vitamin K and magnesium that support calcium absorption.
Summary:
B: Deep red or orange vegetables - While these vegetables are nutritious, they are not significant sources of calcium.
C: White bread and rice - These foods do not provide a significant amount of calcium.
D: Meat, poultry, and fish - While these foods are rich in protein and other nutrients, they are not primary sources of calcium.
A client is in labor and reports increasing rectal pressure. She is experiencing contractions 2 to 3 minutes apart, each lasting 80 to 90 seconds, and a vaginal examination reveals that her cervix is dilated to 9 cm. The client is in which of the following phases of labor?
- A. Active
- B. Transition
- C. Latent
- D. Descent
Correct Answer: B
Rationale: The correct answer is B: Transition. Transition phase occurs when the cervix is dilated from 8 to 10 cm. This phase is characterized by intense contractions close together, increased rectal pressure, and emotional changes. The client in this scenario has contractions 2 to 3 minutes apart, lasting 80 to 90 seconds, and the cervix is dilated to 9 cm. This aligns with the characteristics of the transition phase.
Summary:
A: Active phase occurs when the cervix is dilated from 4 to 7 cm.
C: Latent phase occurs when the cervix is dilated from 0 to 3 cm.
D: Descent phase is not a recognized phase of labor.
A client who is at 24 weeks of gestation is scheduled for a 1-hour glucose tolerance test. Which of the following statements should the nurse include in her teaching?
- A. You will need to drink the glucose solution 1 hour prior to the test.
- B. Limit your carbohydrate intake for 24 hours prior to the test.
- C. A blood glucose of 130 to 140 mg/dL is considered a positive screening result.
- D. You will need to fast for 8 hours prior to the test.
Correct Answer: C
Rationale: The correct answer is C: A blood glucose of 130 to 140 mg/dL is considered a positive screening result. This statement is the correct teaching point because for a 1-hour glucose tolerance test during pregnancy, a blood glucose level of 130-140 mg/dL is considered elevated and may indicate gestational diabetes. The other choices are incorrect: A is wrong because the glucose solution is typically consumed one hour before the test, not prior to the test itself. B is incorrect as limiting carbohydrate intake is not necessary for this test. D is also incorrect because fasting for 8 hours is not required for a 1-hour glucose tolerance test.
During a vaginal exam on a client in labor who reports severe pressure and pain in the lower back, a nurse notes that the fetal head is in a posterior position. Which of the following is the best nonpharmacological intervention for the nurse to perform to relieve the client's discomfort?
- A. Back rub
- B. Counter-pressure
- C. Playing music
- D. Foot massage
Correct Answer: B
Rationale: The correct answer, B: Counter-pressure, is the best nonpharmacological intervention for a client with a posterior fetal head position causing lower back pain. Counter-pressure applied to the sacrum can help alleviate discomfort by reducing pressure on the lower back and providing support during contractions. This technique can aid in rotating the baby's head to a more optimal position for delivery.
Choice A: Back rub, may offer some comfort but may not specifically address the issue of lower back pain caused by the fetal position. Choice C: Playing music, and Choice D: Foot massage, are unlikely to provide direct relief for the client's specific discomfort related to the baby's posterior position.