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A multigravid client in active labor at term suddenly sits up and says, 'I can't breathe! My chest hurts really bad!' The client's skin begins to turn a dusky gray color. After calling for assistance, which of the following should the nurse do next?
- A. Administer oxygen by face mask.
- B. Begin cardiopulmonary resuscitation.
- C. Administer intravenous oxytocin.
- D. Obtain an order for intravenous fibrinogen.
Correct Answer: A
Rationale: Sudden dyspnea, chest pain, and dusky skin suggest a possible pulmonary embolism or amniotic fluid embolism. Administering oxygen improves oxygenation while awaiting further intervention. CPR is premature, oxytocin is irrelevant, and fibrinogen is for coagulopathy.
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A nurse is counseling a client about the use of emergency contraception. Which of the following client statements indicates understanding?
- A. I should take it within 72 hours of unprotected intercourse.
- B. It can be used as a regular contraceptive method.
- C. It requires a surgical procedure.
- D. It is 100% effective in preventing pregnancy.
Correct Answer: A
Rationale: Emergency contraception is most effective when taken within 72 hours of unprotected intercourse. It is not for regular use, does not require surgery, and is not 100% effective.
Assessment reveals that the fetus of a multigravid client is at +1 station and 8 cm dilated. Based on these data, the nurse should first:
- A. Ask anesthesia to increase epidural rate.
- B. Assist the client to push if she feels the need to do so.
- C. Encourage the client to breathe through the urge to push.
- D. Support family members in providing comfort measures.
Correct Answer: C
Rationale: At 8 cm dilation and +1 station, the client is in the transition phase but not fully dilated (10 cm). Pushing before full dilation can lead to cervical edema or lacerations. Encouraging the client to breathe through the urge to push helps prevent premature pushing while supporting labor progression. Increasing the epidural rate or assisting with pushing is inappropriate at this stage, and while family support is valuable, it is not the priority.
A client asks about the differences between the copper IUD and the hormonal IUD. Which of the following responses by the nurse is accurate?
- A. The copper IUD is hormone-free and may increase menstrual bleeding, while the hormonal IUD may reduce bleeding.
- B. Both IUDs require replacement every year.
- C. The copper IUD prevents ovulation, while the hormonal IUD does not.
- D. The hormonal IUD is less effective than the copper IUD.
Correct Answer: A
Rationale: The copper IUD is hormone-free and may increase menstrual bleeding, while the hormonal IUD releases progestin and may reduce bleeding. Both last several years, neither primarily prevents ovulation, and both are highly effective.
A multiparous client, 72 hours postpartum, reports a sudden gush of lochia rubra. The nurse should suspect:
- A. Normal involution.
- B. Uterine subinvolution.
- C. Cervical laceration.
- D. Retained placental fragments.
Correct Answer: D
Rationale: A sudden gush of lochia rubra after 72 hours suggests retained placental fragments, which can cause hemorrhage.
The nurse and a nursing assistant are caring for clients in a birthing center. Which of the following tasks should the nurse delegate to the nursing assistant? Select all that apply.
- A. Removing a Foley catheter from a preeclamptic client.
- B. Assisting an active labor client with breathing and relaxation.
- C. Ambulating a postcesarean client to the bathroom.
- D. Calculating hourly I.V. totals for a preterm labor client.
- E. Intake and output catheterization for culture and sensitivity.
- F. Calling a report of normal findings to the health care provider.
- G. Removing lunch trays and documenting lunch intake.
Correct Answer: C,G
Rationale: Delegating ambulation and lunch tray removal is appropriate for a nursing assistant.