Nokea
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.
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During a scheduled cesarean delivery of a primigravid client with a fetus at 39 weeks' gestation in a breech presentation, a neonatologist is present in the operating room. The nurse explains to the client that the neonatologist is present because neonates born by cesarean delivery tend to have an increased incidence of which of the following?
- A. Congenital anomalies.
- B. Pulmonary hypertension.
- C. Meconium aspiration syndrome.
- D. Respiratory distress syndrome.
Correct Answer: D
Rationale: Cesarean delivery, especially without labor, increases the risk of respiratory distress syndrome due to retained lung fluid. Breech presentation may exacerbate this. Congenital anomalies, pulmonary hypertension, and meconium aspiration are less directly related.
A primigravid client's baseline blood pressure at her initial visit at 12 weeks' gestation was 110/70 mm Hg. During an assessment at 38 weeks' gestation, which of the following data would indicate mild preeclampsia?
- A. Blood pressure of 160/110 mm Hg on two separate occasions.
- B. Proteinuria, more than 5 g in 24 hours.
- C. Serum creatinine concentration of 1.4 mL/dL.
- D. Weight gain of 2 lb in the last week.
Correct Answer: D
Rationale: Sudden weight gain is characteristic of mild preeclampsia.
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.
Which of the following would lead the nurse to suspect retinopathy of prematurity (ROP) when assessing a neonate at 32 weeks' gestation who weighs 2,000 g ?
- A. Sunken orbital sockets.
- B. Strabismus.
- C. Reaction to bright light.
- D. Constricted retinal vessels.
Correct Answer: D
Rationale: Constricted retinal vessels are a sign of ROP, indicating abnormal retinal vascular development.
A 16-year-old primigravid client, with a history of attending one prenatal visit, is admitted to the hospital in active labor at 37 weeks' gestation. Her cervix is 7 cm dilated with the presenting part at 0 station. She enters the labor unit appearing anxious and hyperventilating. Because of the hyperventilation, the nurse should assess the client for:
- A. Metabolic alkalosis.
- B. Metabolic acidosis.
- C. Respiratory alkalosis.
- D. Respiratory acidosis.
Correct Answer: C
Rationale: Hyperventilation causes excessive exhalation of carbon dioxide, leading to respiratory alkalosis (elevated blood pH). Metabolic imbalances are less likely, and respiratory acidosis occurs with hypoventilation.