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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Assessment of a 2-day-old neonate delivered at 34 weeks' gestation reveals absent apical pulse left of the midclavicular line, cyanosis, grunting, and diminished breath sounds. The nurse should first:
- A. Consult with health care provider to obtain a chest x-ray.
- B. Reposition the neonate and then assess if the grunting and cyanosis resolve.
- C. Begin oxygen administration at 6-8 L via mask.
- D. Obtain a complete blood count to determine infection.
Correct Answer: A
Rationale: These symptoms suggest a serious condition like dextrocardia or pneumothorax, and consulting for a chest x-ray is the priority to confirm the diagnosis.
After the nurse teaches a primiparous client planning to return to work in 6 weeks about storing breast milk, which of the following client statements indicates the need for further teaching?
- A. I can let the milk sit out in a bottle for up to 10 hours.
- B. I'll be sure to label the milk with the date, time, and amount.
- C. I can store the milk for 3 days in the refrigerator.
- D. I can keep the milk in a deep-freeze in clean glass bottles for up to 1 year.
Correct Answer: A
Rationale: Breast milk should not be left out for more than 4-6 hours; 10 hours risks spoilage.
The nurse is planning care for a group of pregnant clients. Which of the following clients should be referred to a health care provider immediately?
- A. A woman who is at 10 weeks' gestation, is having nausea and vomiting, and has +1 ketones in her urine.
- B. A woman who is at 37 weeks' gestation and has insulin-dependent diabetes experiencing 2-3 hyperglycemic episodes weekly.
- C. A woman at 32 weeks' gestation and is preeclamptic with +3 proteinuria.
- D. A primigravida at 15 weeks' gestation who reports she is not feeling fetal movement.
Correct Answer: C
Rationale: Severe preeclampsia requires immediate attention.
A newly delivered client is asking to go to the bathroom 45 minutes after delivery. She had an epidural for labor & delivery, has an IV infusing, and every 15 minutes assessments are in progress. To provide the safest care for this client the nurse should:
- A. Ask her to remain in bed until the 15-minute assessments are complete.
- B. Assess client's ability to stand and bear weight before going to the bathroom.
- C. Encourage the client to sit at the side of the bed before ambulating to the bathroom.
- D. Ask the client to ambulate the first time with a staff member at her side.
Correct Answer: B
Rationale: Post-epidural, assessing the client's ability to stand and bear weight ensures safety due to potential residual numbness or weakness. Remaining in bed delays care, sitting first is insufficient, and ambulating with assistance assumes mobility not yet confirmed.
An antenatal G 2, T 1, P 0, Ab 0, L 1 client is discussing her postpartum plans for birth control with the health care provider. In analyzing the available choices, which of the following factors has the greatest impact on her birth control options?
- A. Satisfaction with prior methods.
- B. Preference of sexual partner.
- C. Breast- or bottle-feeding plan.
- D. History of clotting disease.
Correct Answer: D
Rationale: A history of clotting disease significantly impacts birth control options, as hormonal methods like combined oral contraceptives may increase the risk of thromboembolism, making non-hormonal or progestin-only methods safer choices.