Nokea
A multigravid client is admitted at 4-cm dilation and requesting pain medication. The nurse gives the client Nubain 15 mg and Phenergan 25 mg slow I.V. push. Within 5 minutes, the client tells the nurse she feels like she needs to have a bowel movement. The nurse should first:
- A. Have naloxone hydrochloride (Narcan) available in the delivery room.
- B. Perform a vaginal examination to determine dilation, effacement, and station.
- C. Prepare for delivery.
- D. Document the client's relief due to pain medication.
Correct Answer: B
Rationale: A sudden urge to have a bowel movement in labor often indicates rapid progression to full dilation or fetal descent. A vaginal examination confirms dilation and station to guide next steps (e.g., preparing for delivery). Naloxone, preparation, or documentation are premature without assessment.
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A multigravid client diagnosed with a probable ruptured ectopic pregnancy is scheduled for emergency surgery. In addition to monitoring the client's blood pressure before surgery, which of the following would the nurse assess?
- A. Uterine cramping.
- B. Abdominal distention.
- C. Hemoglobin and hematocrit.
- D. Pulse rate.
Correct Answer: D
Rationale: Pulse rate helps assess circulatory status.
A viable female neonate was delivered 10 minutes ago and is in stable condition under a radiant warmer. To prevent infant heat loss by convection, the nurse should:
- A. Move the infant away from cool window surfaces.
- B. Dry the infant quickly after delivery.
- C. Keep the infant away from air conditioning vents.
- D. Place the infant on a warmed surface.
Correct Answer: C
Rationale: Keeping the infant away from air conditioning vents prevents heat loss by convection, which occurs due to air movement.
A client asks about the effectiveness of natural family planning methods. Which of the following responses by the nurse is most accurate?
- A. Natural family planning is as effective as oral contraceptives when used correctly.
- B. The effectiveness of natural family planning depends on consistent monitoring and abstinence during fertile periods.
- C. Natural family planning is less effective than barrier methods like condoms.
- D. Natural family planning requires no special equipment or cost.
Correct Answer: B
Rationale: The effectiveness of natural family planning depends on consistent monitoring and abstinence during fertile periods. It is less effective than oral contraceptives or barrier methods due to variability in ovulation and user adherence.
The nurse is instructing a preeclamptic client about monitoring the movements of her fetus to determine fetal well-being. Which statement by the client indicates that she needs further instruction about when to call the health care provider concerning fetal movement?
- A. "If the fetus is becoming less active than before."
- B. "If it takes longer each day for the fetus to move 10 times."
- C. "If the fetus stops moving for 12 hours."
- D. "If the fetus moves more often than 3 times an hour."
Correct Answer: D
Rationale: Increased fetal movement can be a sign of distress, so the client should be instructed to report any significant changes in movement.
While caring for a primigravid client with class II heart disease at 28 weeks' gestation, the nurse would instruct the client to contact her physician immediately if the client experiences which of the following?
- A. Mild ankle edema.
- B. Emotional stress on the job.
- C. Weight gain of 1 lb in 1 week.
- D. Increased dyspnea at rest.
Correct Answer: D
Rationale: Increased dyspnea at rest can indicate worsening heart function.