Nokea
A multigravid client is receiving oxytocin (Pitocin) augmentation. When the client's cervix is dilated to 6 cm, her membranes rupture spontaneously with meconium-stained amniotic fluid. Which of the following actions should the nurse do first?
- A. Increase the rate of the oxytocin infusion.
- B. Turn the client to a knee-to-chest position.
- C. Assess cervical dilation and effacement.
- D. Monitor the fetal heart rate continuously.
Correct Answer: D
Rationale: Meconium-stained fluid indicates potential fetal distress, requiring immediate continuous fetal heart rate monitoring to assess for complications like cord compression or hypoxia. Increasing oxytocin, repositioning, or reassessing dilation are secondary.
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A client is considering the contraceptive patch. Which of the following instructions should the nurse provide?
- A. Apply a new patch daily for three weeks, then skip a week.
- B. Change the patch weekly for three weeks, then have a patch-free week.
- C. Wear the patch for one month, then replace it.
- D. Apply the patch to the genital area for best results.
Correct Answer: B
Rationale: The contraceptive patch is changed weekly for three weeks, followed by a patch-free week to allow for a withdrawal bleed. It is not applied daily, worn for a month, or placed on the genital area.
A client asks about the effectiveness of the contraceptive patch. Which of the following responses by the nurse is accurate?
- A. The patch is less effective than oral contraceptives.
- B. The patch is highly effective when used correctly.
- C. The patch is 100% effective in preventing pregnancy.
- D. The patch does not require a prescription.
Correct Answer: B
Rationale: The contraceptive patch is highly effective when used correctly, with a failure rate similar to oral contraceptives (about 1% with perfect use). It is not 100% effective, requires a prescription, and is not less effective than pills.
Which of the following would be most important for the nurse to encourage in a primiparous client diagnosed with endometritis who is receiving intravenous antibiotic therapy?
- A. Ambulate to the bathroom frequently.
- B. Discontinue breast-feeding temporarily.
- C. Maintain bed rest in Fowler's position.
- D. Restrict visitors to prevent contamination.
Correct Answer: C
Rationale: Fowler's position promotes drainage of uterine secretions, aiding recovery from endometritis.
A multigravid client is in active labor with twins at 38 weeks' gestation. The nurse should monitor the client closely for symptoms of which of the following?
- A. Pregnancy-induced hypertension.
- B. Urinary tract infection.
- C. Chorioamnionitis.
- D. Precipitous delivery.
Correct Answer: D
Rationale: Twin pregnancies increase the risk of precipitous delivery due to uterine overdistension, which can lead to rapid labor. Hypertension, infections, or chorioamnionitis are possible but less specific to twins.
After the physician explains the prognosis and medical management for atrial septal defect to a primiparous client whose 2-day-old female neonate was diagnosed with this condition, the nurse determines that the mother needs further instructions when she says which of the following?
- A. As my child grows, she may have increased fatigue and difficulty breathing.'
- B. My child may need to have antibiotics if she develops an infection.'
- C. This condition occurs more commonly in females than in males.'
- D. About half of the children born with this defect heal spontaneously.'
Correct Answer: C
Rationale: Atrial septal defects are not significantly more common in females, indicating a need for further instruction.