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A nurse is caring for a client who is 12 hr postpartum and has a fourth-degree laceration of the perineum. Which of the following actions should the nurse take?
- A. Apply a moist, warm compress to the perineum.
- B. Provide the client with a cool sitz bath.
- C. Administer methylergonovine 0.2 mg IM.
- D. Apply povidone-iodine to the client’s perineum after she voids.
Correct Answer: A
Rationale: Correct Answer: A. Apply a moist, warm compress to the perineum.
Rationale: Applying a moist, warm compress helps reduce pain, swelling, and discomfort in the perineal area postpartum. It promotes healing and provides comfort to the client with a fourth-degree laceration. This action also helps improve circulation to the area, aiding in the healing process.
Incorrect Choices:
B: Providing a cool sitz bath may provide relief for hemorrhoids or perineal discomfort but is not the best option for a fourth-degree laceration. Warm compresses are more suitable in this situation.
C: Administering methylergonovine is used to prevent or treat postpartum hemorrhage, not for perineal lacerations.
D: Applying povidone-iodine after voiding is not recommended as it can be irritating to the wound and delay healing.
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A school nurse is providing teaching to an adolescent about levonorgestrel contraception. Which of the following information should the nurse include in the teaching?
- A. You should take the medication within 72 hours following unprotected sexual intercourse.
- B. You should avoid taking this medication if you are on an oral contraceptive.
- C. If you don't start your period within 5 days of taking this medication, you will need a pregnancy test.
- D. One dose of this medication will prevent you from becoming pregnant for 14 days after taking it.
Correct Answer: A
Rationale: The correct answer is A. Levonorgestrel is an emergency contraception pill effective if taken within 72 hours post unprotected sex. This is crucial information for the adolescent to prevent pregnancy. Choice B is incorrect as it does not interact with oral contraceptives. Choice C is incorrect as missing a period does not necessarily indicate pregnancy. Choice D is incorrect as it only provides immediate protection, not for 14 days.
A nurse is assisting the provider to administer a dinoprostone insert to induce labor for a client. Which of the following actions should the nurse take?
- A. Allow the medication to reach room temperature prior to administration.
- B. Place the client in a semi-Fowler’s position for 1 hr after administration.
- C. Instruct the client to avoid urinary elimination until after administration.
- D. Verify that informed consent is obtained prior to administration.
Correct Answer: D
Rationale: Correct Answer: D - Verify that informed consent is obtained prior to administration.
Rationale: Informed consent is a crucial ethical and legal requirement before any medical procedure. It ensures the client is aware of the risks, benefits, and alternatives to the treatment. Verifying informed consent protects the client's autonomy and prevents potential legal issues.
Incorrect Choices:
A: Allowing the medication to reach room temperature is not necessary for the administration of dinoprostone insert.
B: Placing the client in a semi-Fowler's position after administration is not a standard practice for this procedure.
C: Instructing the client to avoid urinary elimination is unnecessary and could lead to discomfort and potential complications.
E, F, G: No additional choices provided, but they would likely be incorrect as well as they do not address the key safety and ethical considerations associated with administering dinoprostone insert for labor induction.
A nurse is performing a routine assessment on a client who is at 18 weeks of gestation. Which of the following findings should the nurse expect?
- A. Deep tendon reflexes 4+
- B. Fundal height 14 cm
- C. Blood pressure 142/94 mm Hg
- D. FHR 152/min
Correct Answer: D
Rationale: The correct answer is D: FHR 152/min. At 18 weeks gestation, the fetal heart rate (FHR) typically ranges from 140-160 beats per minute, making 152/min within the normal range. This finding indicates a healthy fetal heart rate.
A: Deep tendon reflexes 4+ is not relevant to a routine assessment at 18 weeks gestation.
B: Fundal height of 14 cm is more indicative of around 12 weeks gestation, not 18 weeks.
C: Blood pressure of 142/94 mm Hg is elevated and would require further assessment and management, not expected at 18 weeks gestation.
In summary, the FHR of 152/min is the expected finding at 18 weeks gestation, making it the correct answer.
A nurse is caring for a client who is to receive oxytocin to augment their labor. Which of the following findings contraindicates the initiation of the oxytocin infusion and should be reported to the provider?
- A. Late decelerations
- B. Moderate variability of the FHR
- C. Cessation of uterine dilation
- D. Prolonged active phase of labor
Correct Answer: A
Rationale: The correct answer is A: Late decelerations. Late decelerations indicate uteroplacental insufficiency, which can worsen with oxytocin administration due to increased uterine contractions. This can lead to fetal distress and hypoxia. Late decelerations are a sign to stop or decrease the oxytocin infusion and notify the provider. Moderate variability of the FHR (B) is a reassuring sign of fetal well-being. Cessation of uterine dilation (C) may indicate a stalled labor but is not a contraindication for initiating oxytocin. Prolonged active phase of labor (D) may warrant oxytocin augmentation but is not a contraindication.
A nurse is caring for a client who is in labor and reports increasing rectal pressure. They are experiencing contractions 2 to 3 min apart, each lasting 80 to 90 seconds, and a vaginal examination reveals that their cervix is dilated to 9 cm. The nurse should identify that the client is in which of the following phases of labor?
- A. Passive descent
- B. Active
- C. Early
- D. Descent
Correct Answer: B
Rationale: The correct answer is B: Active phase. At 9cm dilation, the client is transitioning from the latent phase to the active phase of the first stage of labor. In the active phase, contractions are stronger and more frequent, leading to increased rectal pressure and cervical dilation. This phase typically ranges from 6-10cm dilation. Passive descent (A) refers to the early phase of labor when the cervix is dilating but contractions are mild. Early phase (C) is characterized by 0-3cm dilation. Descent (D) is not a recognized phase of labor. The client's symptoms align with the characteristics of the active phase, making option B the correct choice.