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Client at 40 weeks gestation, active labor, 6 cm cervical dilation, 100% effacement, blood pressure 82/52 mm Hg
A nurse is caring for a client who is at 40 weeks gestation and is in active labor. The client has 6 cm of cervical dilation and 100% cervical effacement. The nurse obtains the client's blood pressure reading as 82/52 mm Hg. Which of the following nursing interventions should the nurse perform?
- A. Assist the client to turn onto her side.
- B. Prepare for an immediate vaginal delivery.
- C. Prepare for a cesarean birth.
- D. Assist the client to an upright position.
Correct Answer: A
Rationale: Assisting the client to turn onto her side can improve blood flow to the placenta and increase fetal oxygenation, addressing hypotension which is a common cause of decreased uteroplacental perfusion.
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WIC program
The Women, Infants, and Children (WIC) program provides
- A. immunizations for high-risk infants and children.
- B. screening for infants with developmental disorders.
- C. supplemental food supplies to low-income pregnant or breastfeeding women.
- D. well-child examinations for infants and children living at the poverty level.
Correct Answer: C
Rationale: WIC provides supplemental food supplies to low-income pregnant or breastfeeding women and children up to age 5 at nutritional risk.
Woman received 50 mcg fentanyl intravenously 1 hour before delivery
A woman received 50 mcg of fentanyl intravenously 1 hour before delivery. What drug should the nurse have readily available?
- A. Nalbuphine (Nubain).
- B. Naloxone (Narcan).
- C. Butorphanol (Stadol).
- D. Promethazine (Phenergan).
Correct Answer: B
Rationale: Naloxone (Narcan) reverses opioid effects like fentanyl, critical for addressing potential respiratory depression in the newborn.
Student nurse learning about milk production
The student nurse learns that the hormone necessary for milk production is
- A. Estrogen.
- B. Prolactin.
- C. Progesterone.
- D. Lactogen.
Correct Answer: B
Rationale: Prolactin, secreted by the pituitary gland, is responsible for milk production, especially after delivery when estrogen and progesterone levels drop.
Woman post-spinal anesthesia, pounding headache rated 7/10
A woman had spinal anesthesia for delivery. Now she complains of a pounding headache rated 7/10. What action by the nurse is most appropriate?
- A. Place a cool cloth on her forehead and dim the room lights.
- B. Prepare to assist with a blood patch procedure.
- C. Increase the rate of her nonadditive IV fluids.
- D. Give the woman IV opioid pain medications.
Correct Answer: B
Rationale: A pounding headache post-spinal anesthesia suggests a spinal headache from cerebrospinal fluid leakage, best treated with a blood patch to seal the dural puncture.
Newborn boy, 1 minute after birth, heart rate 138 bpm, vigorous crying, spontaneous movement, pink skin with bluish hands and feet
Erin gives birth to a boy. The nurse notes the following on the baby at 1 minute: heart rate is 138 bpm, loud vigorous crying, spontaneous movement and flexion of the extremities, and pink skin color except for a bluish color of the hands and feet. What Apgar score will be assigned to the baby?
- A. 7
- B. 8
- C. 9
- D. 10
Correct Answer: B
Rationale: The baby scores 2 for heart rate (>100 bpm), 2 for respiratory effort (vigorous crying), 2 for muscle tone (spontaneous movement), 2 for reflex irritability (crying), and 1 for color (acrocyanosis), totaling an Apgar score of 8.