Nokea
A multigravid client at term is admitted to the hospital for a trial labor and possible vaginal birth. She has a history of previous cesarean delivery because of fetal distress. When the client is 4 cm dilated, she receives nalbuphine (Nubain) intravenously. While monitoring the fetal heart rate, the nurse observes minimal variability and a rate of 120 bpm. The nurse should explain the decreased variability is most likely caused by which of the following?
- A. Maternal fatigue.
- B. Fetal malposition.
- C. Small-for-gestational-age fetus.
- D. Effects of analgesic medication.
Correct Answer: D
Rationale: Nalbuphine, an opioid, can reduce fetal heart rate variability by depressing the central nervous system, a common side effect. Maternal fatigue, malposition, or small-for-gestational-age fetus are less likely causes.
You may also like to solve these questions
The labor and delivery nurse is assigned to triage for the day. There are four clients already in rooms and the following reports have been received about each of these clients. To provide the safest care and best manage time, the nurse should plan to see which client first?
- A. A primipara in active labor at 5 cm asking to be admitted and wanting an epidural.
- B. A primipara who is 100% effaced, 8 cm dilated, and ready to push.
- C. A multipara who thinks her water broke 2 hours ago.
- D. A multipara with contractions every 5 minutes who is 3 cm dilated.
Correct Answer: B
Rationale: A primipara at 8 cm, 100% effaced, and ready to push is in the second stage of labor, requiring immediate attention to prepare for delivery. Other clients are in earlier stages or need assessment but are less urgent.
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.
After giving instruction about the cause of the vaginal bleeding to a multigravid client at 36 weeks' gestation diagnosed with placenta previa, the nurse determines that the teaching has been effective when the client says that the bleeding results from which of the following?
- A. Diminished clotting factors.
- B. Exposure of maternal blood sinuses.
- C. Increased platelet levels.
- D. A large-for-gestational-age fetus.
Correct Answer: B
Rationale: Placenta previa involves exposure of maternal blood sinuses.
When performing Leopold’s maneuvers on a primigravid client, the nurse is palpating the uterus as shown below. Which of the following maneuvers is the nurse performing?
- A. First maneuver
- B. Second maneuver.
- C. Third maneuver.
- D. Fourth maneuver.
Correct Answer: C
Rationale: The third Leopold’s maneuver is performed to: Identify the fetal part that is lying just above the inlet of the true pelvis (i.e., what part is presenting). It helps determine if the presenting part (usually the head or buttocks) is engaged, floating, or movable.
A multigravid client at 34 weeks' gestation visits the hospital because she suspects that her water has broken. After testing the leaking fluid with nitrazine paper, the nurse confirms that the client's membranes have ruptured when the paper turns which of the following colors?
- A. Yellow.
- B. Green.
- C. Blue.
- D. Red.
Correct Answer: C
Rationale: Nitrazine paper turns blue in the presence of amniotic fluid.