Nokea
A multigravid client at 40 weeks' gestation with a history of previous cesarean delivery is admitted for a trial of labor. The fetal monitor shows late decelerations. Which interventions should the nurse perform? Select all that apply.
- A. Administer oxygen at 8–10 L/min via mask.
- B. Stop the oxytocin infusion.
- C. Reposition the client to her right side.
- D. Increase the IV fluid rate.
- E. Apply a fetal scalp electrode.
Correct Answer: A,B,D
Rationale: Late decelerations suggest uteroplacental insufficiency. Administering oxygen, stopping oxytocin (if running), and increasing IV fluids improve fetal oxygenation and uterine perfusion. Right-side repositioning is less effective than left-side, and scalp electrodes are not the first step.
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During a home visit to a breast-feeding primiparous client at 1 week postpartum, the client tells the nurse that her nipples have become sore and cracked from the feedings. Which of the following should the nurse instruct the client to do?
- A. Wipe off any lanolin creams from the nipple before each feeding.
- B. Position the baby with the entire areola in the baby's mouth.
- C. Feed the baby less often for the next several days.
- D. Use a mild soap while in the shower to prevent an infection.
Correct Answer: B
Rationale: Proper positioning with the areola in the baby's mouth prevents and heals sore nipples.
A 31-year-old multigravid client at 39 weeks' gestation admitted to the hospital in active labor is receiving intravenous lactated Ringer's solution and a continuous epidural anesthetic. During the first hour after administration of the anesthetic, the nurse should monitor the client for:
- A. Hypotension.
- B. Diaphoresis.
- C. Headache.
- D. Tremors.
Correct Answer: A
Rationale: Epidural anesthesia can cause sympathetic blockade, leading to hypotension, especially within the first hour. Monitoring blood pressure is critical. Diaphoresis, headache, or tremors are less common or less urgent.
The nurse managing the admission nursery is beginning the shift. There are 2 infants under the care of a primary staff nurse and are remaining in the nursery while their mothers sleep. One newborn is waiting to be transferred to the special care nursery (SCN) with a diagnosis of possible sepsis. The SCN cannot accept a transfer for 30 minutes. The nurse has been notified that another infant has been born and is breathing at a rate of 80 bpm and needs to be admitted to the nursery. There are also two infants who are waiting for social services to determine discharge plans. There can be no other additions to the nursery until at least one newborn leaves the area. How should the nurse manage this situation?
- A. Ask the nurses in SCN if they can take the newborn with possible sepsis now.
- B. Ask the primary staff nurses to take their babies back to the sleeping mothers' rooms.
- C. Call social services to determine if either of the babies who are waiting to be discharged are ready to leave.
- D. Ask the nurse with the infant who is breathing at 80 bpm to wait ½ hour.
Correct Answer: C
Rationale: Calling social services to expedite discharge of one of the waiting infants allows space for the new admission with a high respiratory rate, which requires urgent assessment.
A client who had a cesarean delivery 24 hours ago complains of pain from abdominal distention. The client has been on nothing-by-mouth status for the past 36 hours. The nurse should:
- A. Offer the client a carbonated beverage twice daily.
- B. Tell the client to use a straw when drinking fluids.
- C. Limit the client to a soft diet until more bowel sounds exist.
- D. Encourage ambulation in the hallway.
Correct Answer: D
Rationale: Ambulation promotes bowel motility, relieving abdominal distention.
A client in sickle cell crisis has been hospitalized during her pregnancy. After giving discharge instructions, the nurse determines the client needs further teaching when she states which of the following?
- A. "I will need more frequent appointments during the remainder of the pregnancy."
- B. "Signs of any type of infection must be reported immediately."
- C. "At the earliest signs of a crisis, I need to seek treatment."
- D. "I have this disease because I don't eat enough food with iron."
Correct Answer: D
Rationale: Sickle cell disease is genetic, not caused by dietary iron deficiency.