Nokea
A laboring client at -2 station has a spontaneous rupture of the membranes and a cord immediately protrudes from the vagina. The nurse should first:
- A. Place gentle pressure upward on the fetal head.
- B. Place the cord back into the vagina to keep it moist.
- C. Begin oxygen by face mask at 8 to 10 L/min.
- D. Turn the client on her left side.
Correct Answer: A
Rationale: Gentle pressure prevents cord compression.
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A 38-year-old client at about 14 weeks' gestation is admitted to the hospital with a diagnosis of complete hydatidiform mole. Soon after admission, the nurse would assess the client for signs and symptoms of which of the following?
- A. Pregnancy-induced hypertension.
- B. Gestational diabetes.
- C. Hypothyroidism.
- D. Polycythemia.
Correct Answer: A
Rationale: Pregnancy-induced hypertension is a common complication of hydatidiform mole.
A multiparous client, 28 hours after cesarean delivery, who is breast-feeding complains of severe cramps or afterpains. The nurse explains that these are caused by which of the following?
- A. Flatulence accumulation after a cesarean delivery.
- B. Healing of the abdominal incision after cesarean delivery.
- C. Adverse effects of the medications administered after delivery.
- D. Release of oxytocin during the breast-feeding session.
Correct Answer: D
Rationale: Breastfeeding stimulates oxytocin release, causing uterine contractions (afterpains) as the uterus involutes.
I.V. oxytocin.png
- A. Continue to observe the fetal monitor.
- B. Anticipate rupture of the membranes.
- C. Prepare for fetal oximetry.
- D. Discontinue the Pitocin infusion.
Correct Answer: D
Rationale: Oxytocin (Pitocin) stimulates uterine contractions. If it causes excessive uterine activity (e.g., more than 5 contractions in 10 minutes or contractions lasting longer than 90 seconds), it can reduce placental perfusion
Assessment of a 23-year-old primigravid client at term who is admitted to the birthing unit in active labor reveals that her cervix is 4 cm dilated and 100% effaced. Contractions are occurring every 4 minutes. The nurse is developing a care plan with the client to relieve pain based on the gate-control theory of pain. The nurse should explain which of the following to the client?
- A. Input from the large sensory fibers opens the gate.
- B. Labor pain is a matter of individual perception.
- C. Slow abdominal breathing can open the gate.
- D. The gating mechanism is in the spinal cord.
Correct Answer: D
Rationale: The gate-control theory posits that pain signals are modulated in the spinal cord, where non-painful stimuli (e.g., touch) can 'close the gate' to pain transmission. Input from large fibers closes the gate, perception varies but is not the mechanism, and slow breathing helps manage pain but does not open the gate.
When caring for a neonate diagnosed with gastroschisis, which of the following actions should the nurse record to do first?
- A. Weigh the neonate.
- B. Insert an orogastric tube.
- C. Prepare for immediate blood transfusion.
- D. Cover the abdomen with a moistened sterile gauze.
Correct Answer: D
Rationale: Covering the abdomen with moistened sterile gauze prevents infection and dehydration of the exposed intestines, which is the first priority.