Nokea
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. Prepare for a cesarean birth.
- B. Assist the client to an upright position.
- C. Prepare for an immediate vaginal delivery.
- D. Assist the client to turn onto her side.
Correct Answer: D
Rationale: Correct Answer: D - Assist the client to turn onto her side.
Rationale:
1. Side-lying position improves placental perfusion and circulation, optimizing blood pressure.
2. This position also helps in relieving pressure on major blood vessels, preventing hypotension.
3. It is a non-invasive intervention that can be quickly implemented in the labor setting.
Summary of Other Choices:
A: Preparing for a cesarean birth is not indicated based solely on the client's blood pressure reading.
B: Assisting the client to an upright position may further decrease blood pressure and compromise perfusion.
C: Immediate vaginal delivery is not warranted solely based on the client's blood pressure and cervical dilation.
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What statement by a health-care provider is an example of shared decision making between a health-care provider and a patient?
- A. I'm going to start this medication because it is best for your baby.
- B. Can you agree with me because I am your health-care provider?â€
- C. I understand how the hospital works, and it will be easier for you to just do what is easy for the nurses.â€
- D. Do you feel ready to make a decision after we talked about this medication?â€
Correct Answer: D
Rationale: The correct answer is D because it involves the patient in the decision-making process by asking for their readiness to make a decision after discussing the medication. This approach respects the patient's autonomy and encourages them to actively participate in their healthcare choices.
A is incorrect as it does not involve the patient in the decision-making process but rather imposes the provider's choice. B is incorrect as it uses authority to influence the patient's decision, which is not in line with shared decision making. C is incorrect as it focuses on convenience rather than involving the patient in the decision-making process.
Which client teaching instruction is necessary for a pregnant client who is to undergo a glucose challenge test (GCT) as part of a routine pregnancy treatment plan at 28 weeks?
- A. No dietary restriction (done 24-28 weeks' gestation)
Correct Answer: A
Rationale: The correct answer is A: No dietary restriction (done 24-28 weeks' gestation). This is because the glucose challenge test (GCT) is typically performed between 24-28 weeks of gestation to screen for gestational diabetes. It is important not to have any dietary restrictions before the test to ensure accurate results. Restricting food intake before the test can lead to false results. Other choices are incorrect because they do not align with the standard practice of performing the GCT between 24-28 weeks and avoiding dietary restrictions before the test.
The nurse is assessing a client with suspected placenta previa. Which finding supports this diagnosis?
- A. Painful, bright red bleeding.
- B. Painless, bright red bleeding.
- C. Hard, rigid abdomen.
- D. Decreased fetal movements.
Correct Answer: B
Rationale: The correct answer is B: Painless, bright red bleeding. Placenta previa is characterized by painless vaginal bleeding due to the placenta covering the cervical os. Bright red blood indicates fresh bleeding from the lower uterus. This finding supports the diagnosis as it aligns with the classic presentation of placenta previa.
A: Painful, bright red bleeding is not characteristic of placenta previa, as the bleeding is usually painless.
C: A hard, rigid abdomen is more indicative of a uterine rupture or abruption, not placenta previa.
D: Decreased fetal movements are not directly associated with placenta previa; this finding may suggest fetal distress but is not specific to this condition.
As the infant nursery nurse, you are assisting with a
- A. Assess the fetal station delivery. After the initial assessment of the baby,
- B. Assess for rupture of the fetal membranes what is the next best action?
- C. Determine dilation of the cervix
- D. Give the infant a bath
Correct Answer: C
Rationale: Rationale for Correct Answer (C - Determine dilation of the cervix):
1. It is crucial to monitor the progress of labor by assessing cervical dilation.
2. Cervical dilation indicates the stage of labor and helps determine when the mother is ready to push.
3. This information guides the healthcare team in providing appropriate care and support during delivery.
4. Assessing fetal station or rupture of membranes is important but determining cervical dilation is the priority.
Summary:
- Option A is incorrect because assessing fetal station is not the immediate next step.
- Option B is incorrect as assessing for rupture of membranes is important but not the next immediate action.
- Option D is incorrect as giving the infant a bath is not a priority in the labor and delivery process.
A client at 28 weeks' gestation is undergoing a glucose tolerance test. What is the purpose of this test?
- A. To detect anemia.
- B. To screen for gestational diabetes.
- C. To assess fetal growth.
- D. To evaluate placental function.
Correct Answer: B
Rationale: The correct answer is B: To screen for gestational diabetes. The glucose tolerance test during pregnancy helps to identify women at risk for developing gestational diabetes, a condition that can lead to complications for both the mother and baby. By measuring blood sugar levels after consuming a glucose solution, healthcare providers can assess how the body processes sugar during pregnancy. This test is specifically designed to detect abnormalities in glucose metabolism during pregnancy.
Choice A: To detect anemia - Anemia is not typically identified through a glucose tolerance test. Anemia is usually diagnosed through a blood test that measures hemoglobin levels.
Choice C: To assess fetal growth - Fetal growth is usually monitored through ultrasound scans and measurements, not through a glucose tolerance test.
Choice D: To evaluate placental function - Placental function is evaluated through other tests like Doppler ultrasound, not through a glucose tolerance test.