Nokea
A nurse in the labor and delivery triage unit assesses a client who has been pushing for 2.5 hours with minimal progress. The fetal head remains at +2 station. Which of the following is the most appropriate next action?
- A. Perform a vaginal exam to reassess effacement and dilation.
- B. Notify the primary health care provider about minimal progress.
- C. Prepare the client for vacuum-assisted delivery.
- D. Administer intravenous oxytocin.
Correct Answer: B
Rationale: Notifying the primary health care provider about minimal progress is the most appropriate next action. The client has been pushing for 2.5 hours with minimal progress, which raises concern for potential complications such as cephalopelvic disproportion or maternal exhaustion.
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A nurse is caring for a client who is in active labor. The nurse notes early decelerations of the FHR on the fetal monitor tracing. The nurse should identify that which of the following conditions causes early decelerations in the FHR?
- A. Fetal hypoxemia.
- B. Uteroplacental insufficiency.
- C. Cord compression.
- D. Head compression.
Correct Answer: D
Rationale: Early decelerations result from fetal head compression, stimulating the vagus nerve and leading to transient heart rate decreases. This is common during contractions.
A nurse is caring for a client who is in labor and has an epidural for pain control. Which of the following clinical manifestations is an adverse effect of epidural anesthesia?
- A. Polyuria.
- B. Hypertension.
- C. Pruritus.
- D. Dry mouth.
Correct Answer: C
Rationale: Pruritus is a frequent side effect of epidural anesthesia, particularly when using opioids like fentanyl, due to histamine release or opioid receptors activation in the spinal cord.
A nurse is teaching the parent of a newborn about car seat safety. Which of the following statements should the nurse make?
- A. You should keep the car seat rear-facing until your baby is at least 2 years old.
- B. Position the retainer clip over the upper part of your baby's abdomen.
- C. You should place your baby in the car seat at a 90-degree angle.
- D. Place the shoulder harness straps in the slots an inch above your baby's shoulders.
Correct Answer: A
Rationale: Rear-facing car seats support a baby's head and spine during sudden stops or collisions. Experts recommend maintaining this position until 2 years to reduce injury risk.
A nurse is providing teaching to a client who has fibrocystic breast changes and is experiencing breast discomfort during menstruation. Which of the following instructions should the nurse include?
- A. Increase your potassium intake.
- B. Increase your fluid intake to 3 liters per day.
- C. Refrain from consuming alcohol.
- D. Limit your daily intake of fiber.
Correct Answer: C
Rationale: Alcohol consumption can worsen fibrocystic breast discomfort due to its estrogen-modulating effects, which may exacerbate hormonal fluctuations during menstruation, increasing breast pain and sensitivity.
A nurse is caring for a client who has a prescription for ibuprofen to treat postpartum cramping. Which of the following questions should the nurse ask prior to administering the medication?
- A. Are you taking over-the-counter medications?
- B. Do you have a history of gastric problems?
- C. What kind of contraception will you be using?
- D. Are you being treated for high blood pressure?
Correct Answer: A
Rationale: Ibuprofen can interact with various over-the-counter medications, including anticoagulants and corticosteroids, which may increase risks of side effects like gastrointestinal bleeding or reduced efficacy, necessitating careful assessment of concurrent drug use.