Nokea
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.
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A client who is 12 hours postpartum has a fundus located two fingerbreadths above the umbilicus, deviated to the right of the midline, and less firm than previously noted. Which of the following actions should the nurse take?
- A. Place the client in a side-lying position.
- B. Assist the client to the bathroom to void.
- C. Obtain a prescription for IV oxytocin.
- D. Administer methylergonovine.
Correct Answer: B
Rationale: The correct answer is B: Assist the client to the bathroom to void. This action can help promote uterine contractions by relieving bladder distention, which can cause the fundus to be displaced. Voiding can help the uterus return to its normal position and firmness. Placing the client in a side-lying position (A) may be helpful for fundal massage but addressing bladder distention is the priority. Obtaining a prescription for IV oxytocin (C) or administering methylergonovine (D) are not indicated as first-line interventions for a fundus located above the umbilicus postpartum.
A client is reinforcing discharge teaching with a client who has premature rupture of membranes at 26 weeks of gestation. Which of the following instructions should the client include?
- A. Use a condom with sexual intercourse
- B. Avoid bubble bath solution when taking a tub bath
- C. Wipe from front to back when performing perineal hygiene
- D. Keep a daily record of fetal kick counts
Correct Answer: D
Rationale: The correct answer is D: Keep a daily record of fetal kick counts. This is important for monitoring fetal well-being, especially in cases of premature rupture of membranes. By counting fetal kicks daily, the client can assess fetal movements and report any changes promptly to healthcare providers. This helps in early detection of fetal distress or problems.
A: Using a condom with sexual intercourse is not relevant to the situation of premature rupture of membranes.
B: Avoiding bubble bath solution is important for preventing vaginal infections but not directly related to monitoring fetal well-being.
C: Wiping from front to back during perineal hygiene is a general hygiene practice and not specific to the situation of premature rupture of membranes.
A charge nurse on the postpartum unit is observing a newly licensed nurse who is preparing to administer pain medication to a client. The charge nurse should intervene when the newly licensed nurse uses which of the following secondary identifiers to identify the client?
- A. The client's room number
- B. The client's telephone number
- C. The client's birth date
- D. The client's medical record number
Correct Answer: A
Rationale: The correct answer is A: The client's room number. Using the client's room number as a secondary identifier is not appropriate as it does not uniquely identify the client and can lead to errors. The room number may change, or there could be multiple clients in the same room. Telephone number, birth date, and medical record number are more reliable secondary identifiers as they are unique to the client and less likely to be confused with another individual. It is essential to use accurate and reliable identifiers to ensure patient safety and prevent medication errors.
A client is being educated by a healthcare provider about potential adverse effects of implantable progestins. Which of the following adverse effects should the healthcare provider include? (Select all that apply)
- A. Nausea
- B. Irregular vaginal bleeding
- C. Weight gain
- D. All of the Above
Correct Answer: D
Rationale: The correct answer is D: All of the Above. Implantable progestins are hormonal contraceptives known to cause common adverse effects such as nausea, irregular vaginal bleeding, and weight gain. Nausea is a common side effect due to hormonal changes. Irregular vaginal bleeding can occur as a result of hormonal imbalance. Weight gain is a known side effect associated with progestin use. Therefore, all of the listed adverse effects should be included in the client education. Other choices are incorrect because they do not encompass the full range of potential adverse effects associated with implantable progestins.
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.