Nokea
A nurse is admitting a client to the birthing unit who reports her contractions started 1 hr ago. The nurse determines the client is 80% effaced and 8 cm dilated. The nurse realizes that the client is at risk for which of the following conditions?
- A. Ectopic pregnancy
- B. Hyperemesis gravidarum
- C. Incompetent cervix
- D. Postpartum hemorrhage
Correct Answer: D
Rationale: The correct answer is D: Postpartum hemorrhage. The client being 80% effaced and 8 cm dilated indicates she is in active labor, not experiencing an ectopic pregnancy, hyperemesis gravidarum, or incompetent cervix. Postpartum hemorrhage is a potential risk due to the advanced stage of labor, increasing the likelihood of excessive bleeding post-delivery. It is crucial for the nurse to monitor the client closely for signs of hemorrhage and be prepared to intervene promptly to prevent complications.
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A nurse is teaching about clomiphene citrate to a client who is experiencing infertility. Which of the following adverse effects should the nurse include?
- A. Breast tenderness
- B. Tinnitus
- C. Urinary frequency
- D. Chills
Correct Answer: A
Rationale: The correct answer is A: Breast tenderness. Clomiphene citrate is a medication commonly used to treat infertility by stimulating ovulation. Breast tenderness is a common side effect due to the hormonal changes it induces, as it can lead to increased estrogen levels. This is important for the nurse to include in teaching as it prepares the client for a potential adverse effect.
B: Tinnitus, C: Urinary frequency, D: Chills are not typically associated with clomiphene citrate use. Tinnitus is more commonly linked to ototoxic medications, urinary frequency is not a known side effect of clomiphene, and chills are not a typical reaction to this medication. It is essential for the nurse to focus on the most relevant and common adverse effects to ensure the client's understanding and safety.
A nurse is caring for a client who delivered by cesarean birth 6 hr ago. The nurse notes a steady trickle of vaginal bleeding that does not stop with fundal massage. Which of the following actions should the nurse take?
- A. Replace the surgical dressing.
- B. Evaluate urinary output.
- C. Apply an ice pack to the incision site.
- D. Administer 500 mL lactated Ringer’s IV bolus.
Correct Answer: D
Rationale: The correct answer is D: Administer 500 mL lactated Ringer’s IV bolus. This action is necessary to address the persistent vaginal bleeding after cesarean birth, as it could be a sign of postpartum hemorrhage. Administering IV fluids helps to improve circulating volume and maintain adequate perfusion to vital organs. This can help stabilize the client's condition while further assessments and interventions are carried out.
Choice A: Replacing the surgical dressing does not address the underlying cause of the bleeding and is not a priority at this time.
Choice B: Evaluating urinary output is important but not the immediate action needed to address the vaginal bleeding.
Choice C: Applying an ice pack to the incision site is not appropriate for controlling postpartum bleeding.
In summary, administering IV fluids is the priority to address potential postpartum hemorrhage, while the other options do not directly address the urgent issue at hand.
A nurse is caring for a client who is 1 hr postpartum and has uterine atony. The client is exhibiting a large amount of vaginal bleeding. Which of the following actions should the nurse take?
- A. Administer betamethasone IM.
- B. Avoid performing sterile vaginal examinations.
- C. Anticipate a prescription for misoprostol.
- D. Obtain a specimen for a Kleihauer-Betke test.
Correct Answer: C
Rationale: Correct Answer: C. Anticipate a prescription for misoprostol.
Rationale: Misoprostol is a medication that helps to induce uterine contractions, which can help control postpartum bleeding due to uterine atony. It is a common pharmacological intervention for this situation.
Incorrect Choices:
A: Administering betamethasone IM is not indicated for postpartum hemorrhage due to uterine atony. This medication is typically used for fetal lung maturation in preterm labor.
B: Avoiding performing sterile vaginal examinations does not address the primary concern of uterine atony and postpartum bleeding. Assessing the uterus and bleeding are crucial in this situation.
D: Obtaining a specimen for a Kleihauer-Betke test is used to determine the amount of fetal-maternal hemorrhage in Rh-negative women. While important in some situations, it is not the priority in managing postpartum hemorrhage.
A nurse is caring for a client who is in active labor with a fetus in the occipitoposterior position. The nurse assists the client into a hands-and-knees position. Which of the following questions should the nurse ask to evaluate the effectiveness of this intervention?
- A. Does that lessen your suprapubic pain?
- B. Are you feeling relief from your pelvic pressure?
- C. Do your contractions feel further apart?
- D. Has your back labor improved?
Correct Answer: D
Rationale: The correct answer is D: "Has your back labor improved?" In the occipitoposterior position, the baby's head is pressing against the mother's back, causing intense back pain. Placing the client in a hands-and-knees position can help alleviate this discomfort by encouraging the baby to rotate into a more favorable position. By asking if the back labor has improved, the nurse can directly assess the effectiveness of the intervention.
Incorrect choices:
A: "Does that lessen your suprapubic pain?" - This question is not directly related to the occipitoposterior position or the hands-and-knees intervention.
B: "Are you feeling relief from your pelvic pressure?" - While pelvic pressure may be present, the primary concern with the occipitoposterior position is back labor.
C: "Do your contractions feel further apart?" - Contractions may not necessarily change in frequency with a change in position, especially in cases of fetal malposition.
A nurse is caring for a client who is at 20 weeks of gestation and has trichomoniasis. Which of the following findings should the nurse expect?
- A. Thick, white vaginal discharge
- B. Urinary frequency
- C. Vulva lesions
- D. Malodorous discharge
Correct Answer: D
Rationale: The correct answer is D: Malodorous discharge. Trichomoniasis is a sexually transmitted infection caused by a parasite, leading to a foul-smelling vaginal discharge. At 20 weeks of gestation, the nurse should expect this symptom due to the infection. Thick, white vaginal discharge (choice A) is more indicative of a yeast infection. Urinary frequency (choice B) is not typically associated with trichomoniasis. Vulva lesions (choice C) are more commonly seen in herpes infection. Therefore, the malodorous discharge (choice D) aligns with the expected finding in a client with trichomoniasis at 20 weeks of gestation.