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A multigravida client arrives at the labor and delivery unit and tells the nurse that her bag of water has broken. The nurse identifies the presence of meconium fluid on the perineum and determines the fetal heart rate is between 140 to 150 beats/minute. What action should the nurse implement next?
- A. Complete a sterile vaginal exam
- B. Take maternal temperature every 2 hours
- C. Prepare for an immediate cesarean birth
- D. Obtain sterile suction equipment
Correct Answer: A
Rationale: A vaginal exam (A) should be performed after the rupture of membranes to determine the presence of a prolapsed cord.
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The nurse is writing an expected outcome for the nursing diagnosis—acute pain related to tissue trauma, secondary to vaginal birth, as evidenced by patient stating pain of 8 on a scale of 10. Which expected outcome is correctly stated for this problem?
- A. Patient will state that pain is a 2 on a scale of 10.
- B. Patient will have a reduction in pain after administration of the prescribed analgesic.
- C. Patient will state an absence of pain 1 hour after administration of the prescribed analgesic.
- D. Patient will state that pain is a 2 on a scale of 10, 1 hour after the administration of the prescribed analgesic.
Correct Answer: D
Rationale: The outcome should be patient-centered, measurable, realistic, and attainable within a specified timeframe.
In order to increase the absorption of iron by a pregnant patient, which beverage should an iron preparation be given with?
- A. Tea
- B. Milk
- C. Coffee
- D. Orange juice
Correct Answer: D
Rationale: To increase iron absorption, it should be taken with Vitamin C. Orange juice is high in Vitamin C, which enhances non-heme iron absorption. Tea and coffee contain tannins that inhibit iron absorption. Milk contains calcium, which can interfere with iron absorption. Therefore, the correct choice is D as it provides the necessary Vitamin C to improve iron absorption.
The healthcare provides prescribes 10 units/L of oxytocin (Pitocin) via IV drips to augment a client labor because she is experiencing a prolonged active phase. Which finding would cause the nurse to immediately discontinue the oxytocin?
- A. Uterus soft
- B. Contraction duration of 100 seconds
- C. Four contractions in 10 minutes
- D. Early deceleration of fetal heart rate
Correct Answer: B
Rationale: Contractions lasting longer than 90 seconds (B) can compromise fetal oxygenation and require discontinuing oxytocin.
Following the vaginal delivery of a large-for-gestation-age (LGA) infant a woman is admitted to the intensive care unit due to postpartum hemorrhaging. The client's medical record lists the client's religion as Jehovah's Witness. What action should the nurse take?
- A. Prepare to infuse multiple units of fresh frozen plasma
- B. Inform the client of the critical need for a blood transfusion
- C. Clarify the clients wishes about receiving blood products
- D. Obtain consent from the family to infuse packed red blood cells
Correct Answer: C
Rationale: Clarifying the client's wishes regarding blood products (C) respects her religious beliefs.
A pregnant woman of normal weight enters her 13th week of pregnancy. If the patient eats and exercises as directed, what will the nurse anticipate as the ongoing weight gain for the remaining trimesters?
- A. 0.3 lb every week
- B. 1 lb every week
- C. 1.8 lb every week
- D. 2 lb every week
Correct Answer: B
Rationale: The correct answer is B: 1 lb every week. During the second and third trimesters, a pregnant woman is expected to gain about 1 lb per week on average. This weight gain is important for the healthy development of the baby and to support the mother's changing body. Gaining weight too slowly can lead to complications, while gaining too quickly can also have negative effects. Choices A, C, and D are incorrect because they suggest weight gain rates that are either too low or too high for a healthy pregnancy. It is crucial for the nurse to educate the patient on the importance of appropriate weight gain throughout the remaining trimesters to ensure the well-being of both the mother and the baby.