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A client in labor with ruptured membranes is diagnosed with chorioamnionitis. What is the priority nursing action?
- A. Administer prescribed antibiotics.
- B. Encourage the client to ambulate.
- C. Increase the oxytocin infusion rate.
- D. Perform a sterile vaginal examination.
Correct Answer: A
Rationale: The correct answer is A: Administer prescribed antibiotics. The priority nursing action in a client with chorioamnionitis is to administer antibiotics promptly to prevent infection spread to the fetus and mother. Antibiotics help treat the infection and reduce complications. Encouraging ambulation (B) may not be safe due to the risk of infection. Increasing oxytocin infusion rate (C) could worsen the infection. Performing a sterile vaginal examination (D) is contraindicated as it can introduce more bacteria. Administering antibiotics is the most urgent and effective intervention in this situation.
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The nurse is monitoring a client during the first stage of labor. What finding requires immediate intervention?
- A. Contractions every 3–5 minutes.
- B. Baseline fetal heart rate of 110 beats/minute.
- C. Variable decelerations on the fetal monitor.
- D. Client reports back pain during contractions.
Correct Answer: C
Rationale: The correct answer is C because variable decelerations on the fetal monitor indicate umbilical cord compression, which can lead to fetal distress and hypoxia. Immediate intervention is needed to relieve the compression and prevent potential harm to the baby. Contractions every 3-5 minutes (A) are normal in the first stage of labor. A baseline fetal heart rate of 110 beats/minute (B) is within the normal range for a fetus. Client reporting back pain (D) is a common symptom of labor and not necessarily indicative of a complication requiring immediate intervention.
The nursing instructor asks the student to describe fetal circulation, specifically the ductus venosus. Which statement by the student indicates an understanding?
- A. It connects the pulmonary artery to the aorta.
- B. It is an opening between the right and left atria.
- C. It connects the umbilical vein to the inferior vena cava.
- D. It connects the umbilical artery to the inferior vena cava.
Correct Answer: C
Rationale: The correct answer is C because the ductus venosus is a fetal vessel that connects the umbilical vein to the inferior vena cava, allowing oxygenated blood from the placenta to bypass the liver and flow directly to the fetal heart. Choice A is incorrect because the ductus arteriosus connects the pulmonary artery to the aorta. Choice B is incorrect as it refers to the foramen ovale, which is an opening between the right and left atria. Choice D is incorrect as it describes the ductus deferens, a part of the male reproductive system.
A nurse in the emergency department is admitting a client who is at 40 weeks of gestation, has ruptured membranes, and the nurse observes the newborn's head is crowning. The client tells the nurse she wants to push. Which of the following statements should the nurse make? to
- A. "You should go ahead and push to assist the delivery."
- B. "You should try to pant as the delivery proceeds."
- C. "You should try to perform slow-paced breathing."
- D. "You should take a deep, cleansing breath and breathe naturally."
Correct Answer: A
Rationale: The correct answer is A because the newborn's head crowning indicates imminent delivery, and the client's urge to push aligns with the natural progression of labor. By encouraging the client to push, the nurse facilitates the safe and timely delivery of the baby. Panting (choice B) or slow-paced breathing (choice C) may not be effective in this advanced stage of labor. Taking a deep cleansing breath (choice D) can delay the delivery and is not recommended when the baby is crowning.
A nurse is preparing to administer magnesium sulfate IV to a client who is experiencing preterm labor. Which of the following is the priority nursing assessment for this client?
- A. Temperature
- B. Fetal heart rate (FHR)
- C. Bowel sounds
- D. Respiratory rate
Correct Answer: B
Rationale: The correct answer is B: Fetal heart rate (FHR). When administering magnesium sulfate for preterm labor, monitoring the fetal heart rate is crucial as magnesium sulfate can affect the fetal heart rate. It is important to assess for any signs of fetal distress promptly.
A: Temperature is important to monitor for signs of magnesium toxicity, but not the priority assessment in this situation.
C: Bowel sounds are not directly related to the administration of magnesium sulfate for preterm labor.
D: Respiratory rate is important to monitor for respiratory depression from magnesium sulfate, but assessing the fetal heart rate takes precedence in this scenario.
A nurse is assessing a client who received magnesium sulfate to treat preterm labor. Which of the following clinical findings should the nurse identify as an indication of toxicity of magnesium sulfate therapy and report to the provider?
- A. Respiratory depression
- B. Facial flushing
- C. Nausea
- D. Drowsiness
Correct Answer: A
Rationale: The correct answer is A: Respiratory depression. Respiratory depression is a serious sign of magnesium sulfate toxicity as it can progress to respiratory arrest. Magnesium sulfate acts as a central nervous system depressant, leading to muscle weakness and respiratory depression. Facial flushing is a common side effect but not indicative of toxicity. Nausea and drowsiness are common side effects of magnesium sulfate therapy and are not specific signs of toxicity. Reporting respiratory depression promptly is crucial to prevent further complications.