Nokea
A client on the obstetric unit is receiving IV medications per physician’s orders. On rounds the nurse notes that the client’s IV has infiltrated. Which of the following actions should the nurse perform first?
- A. Determine whether the infusion is a vesicant.
- B. Stop the infusion and remove the catheter.
- C. Document the occurrence in the medical record.
- D. Elevate the extremity and monitor the site.
Correct Answer: B
Rationale: Stopping the infusion and removing the catheter prevents further tissue damage from the infiltrated medication.
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Which information is covered by early pregnancy classes offered in the first and second trimesters?
- A. Methods of pain relief
- B. The phases and stages of labor
- C. Coping with common discomforts of pregnancy
- D. Prebirth and postbirth care of a patient having a cesarean birth
Correct Answer: C
Rationale: The correct answer is C: Coping with common discomforts of pregnancy. Early pregnancy classes in the first and second trimesters focus on providing expecting mothers with strategies to manage common physical and emotional challenges during pregnancy. This includes information on dealing with nausea, fatigue, backaches, and emotional changes. Understanding and coping with these discomforts can help pregnant women have a more comfortable and healthy pregnancy.
A: Methods of pain relief are typically covered in childbirth preparation classes closer to the due date, not in early pregnancy classes.
B: The phases and stages of labor are usually discussed in depth in childbirth education classes taken later in pregnancy, not in early pregnancy classes.
D: Prebirth and postbirth care of a patient having a cesarean birth is a specific topic that may be covered in a separate class for women who are planning or have been recommended to have a cesarean birth, not typically in early pregnancy classes.
The nurse is teaching her client about the methods of electronic fetal monitoring during labor. Her client asks which method has the fewest risks to her baby and allows her the most freedom. What is the most appropriate response by the nurse?
- A. Internal and external monitoring have equal risks. You will have to remain in the bed with both of these methods.'
- B. Internal monitoring is a more invasive method, but we only use internal monitoring if we have difficulty obtaining accurate information with external monitoring.'
- C. External monitoring will allow you the most freedom of movement and does not require any invasive procedures for you or your baby.'
- D. External monitoring is not invasive but you have to remain in the bed.'
Correct Answer: C
Rationale: The correct answer is C because external monitoring allows the client the most freedom of movement and does not require any invasive procedures for her or the baby. External monitoring involves placing sensors on the abdomen to monitor the baby's heart rate and the mother's contractions. This method is non-invasive and allows the mother to move around during labor, promoting comfort and mobility.
Choice A is incorrect because internal monitoring is more invasive than external monitoring. Choice B is incorrect because internal monitoring is not used solely based on difficulty obtaining accurate information with external monitoring. Choice D is incorrect because external monitoring does not require the mother to remain in bed; she can move around freely.
The nurse is teaching a woman how to do the pelvic tilt exercise. In the teaching session, which of the following should the nurse tell the woman to do?
- A. Stand with the back of her heels and shoulders touching a wall.
- B. Bend laterally back and forth from one side to the other.
- C. Move so that her back alternately is concave and convex.
- D. Lie flat on her back and move her hips from side to side.
Correct Answer: C
Rationale: Pelvic tilt exercises involve alternating the back between concave and convex positions to strengthen the lower back and abdominal muscles.
A doula is working with a laboring woman who is 6 cm dilated and is contracting every 3 min × 60 sec on an oxytocin drip. Which of the following interventions should the nurse suggest the doula perform?
- A. Regulate the oxytocin drip rate.
- B. Check the vaginal dilation of the client.
- C. Encourage the woman to use breathing techniques.
- D. Monitor the client for uterine hyperstimulation.
Correct Answer: C
Rationale: The doula's role is to provide emotional and physical support, such as encouraging breathing techniques. Regulating medications and monitoring for complications are the nurse's responsibilities.
What is the purpose of initiating contractions in a contraction stress test (CST)?
- A. Increase placental blood flow.
- B. Identify fetal acceleration patterns.
- C. Determine the degree of fetal activity.
- D. Apply a stressful stimulus to the fetus.
Correct Answer: D
Rationale: The purpose of initiating contractions in a contraction stress test (CST) is to apply a stressful stimulus to the fetus to assess its response to stress, mimicking the stress of labor. This helps evaluate fetal well-being by monitoring the fetal heart rate during contractions. A: Increasing placental blood flow is not the primary purpose of CST. B: Identifying fetal acceleration patterns is not the main goal of CST. C: Determining the degree of fetal activity is not the primary objective of CST. The correct answer is D as it reflects the main purpose of initiating contractions in a CST.