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A nurse is caring for a client who is gravida 3, para 2, and is in active labor. The fetal head is at 3+ station after a vaginal examination. Which of the following actions should the nurse take
- A. Apply fundal pressure.
- B. Observe for the presence of a nuchal cord.
- C. Observe for crowning.
- D. Prepare to administer oxytocin.
Correct Answer: C
Rationale: Observing for crowning is the appropriate action for the nurse to take when the fetal head is at 3+ station after a vaginal examination. Crowning refers to the appearance of the baby's head at the vaginal opening during delivery. This indicates that the baby is descending and will be born soon. It is important for the nurse to be prepared for the actual birth once crowning is observed, as it signifies that the second stage of labor is progressing and delivery is imminent. Applying fundal pressure, observing for a nuchal cord, or preparing to administer oxytocin are not appropriate actions at this stage of labor when crowning has been observed.
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The nurse is describing different types of abruptio placenta to a group of students explaining that the incomplete abruptio placenta is
- A. There is massive bleeding in the presence of almost total separation
- B. Separation beginning at the periphery of the placenta
- C. The placenta separates centrally and there can be concealed bleeding
- D. Blood passes between the fetal membrane of the uterine wall and is skipped vaginally
Correct Answer: B
Rationale: In incomplete abruptio placenta, the separation begins at the periphery of the placenta. This results in partial detachment of the placenta from the uterine wall, rather than almost total separation as seen in complete abruptio placenta. This type of abruptio placenta may present with vaginal bleeding depending on the extent of separation and may lead to various degrees of maternal and fetal compromise.
A nurse is caring for a client who is receiving oxytocin to augment labor. The nurse notes recurrent variable decelerations...Which of the following actions should the nurse take first?
- A. Prepare the equipment necessary to initiate an amnioinfusion.
- B. Administer oxygen at 10 L/min via nonrebreather face mask.
- C. Discontinue the infusion of oxytocin.
- D. Place the client in a left lateral position.
Correct Answer: C
Rationale: Recurrent variable decelerations during labor can indicate umbilical cord compression, which can result in fetal hypoxia and distress. Discontinuing the oxytocin infusion is the priority in this situation as oxytocin can cause or exacerbate uteroplacental insufficiency leading to fetal distress. By discontinuing the oxytocin, the nurse can help improve fetal oxygenation and alleviate the variable decelerations. After stopping the oxytocin infusion, the nurse should continue to monitor the fetal heart rate pattern and follow the healthcare provider's orders for further management if needed.
How should a nurse respond to a mother asking about newborn hearing screening?
- A. Explain that hearing screening is optional
- B. Reassure the mother that this is a routine test
- C. Inform the mother that hearing screening is mandatory
- D. Provide resources for further testing if needed
Correct Answer: B
Rationale: Hearing screening is a routine test to identify hearing issues early and ensure proper interventions.
A woman is experiencing mittelschmerz and increased vaginal discharge. Her temperature has increased by 0.6°C (1.0°F) over the past 36 hours. This most likely indicates what?
- A. Menstruation is about to begin.
- B. Ovulation will occur soon.
- C. Ovulation has occurred.
- D. She is pregnant, and will not menstruate.
Correct Answer: C
Rationale: Mittelschmerz, or mid-cycle pain, combined with a basal temperature rise and cervical mucus changes, is a sign that ovulation has occurred. These indicators are part of the body's natural fertility signals.
A nurse is caring for a client who is in premature labor and is receiving terbutaline. The nurse should monitor the client for which of the following adverse effects that should be reported to the provider?
- A. Headaches B Nervousness
- B. Tremors
- C. Dyspnea
Correct Answer: C
Rationale: Terbutaline is a beta-adrenergic agonist that is commonly used to suppress preterm labor by relaxing the uterine smooth muscle. Adverse effects of terbutaline can include respiratory distress or dyspnea, which is a serious concern and should be reported to the healthcare provider immediately. Both the nurse and the client should be alert for signs of difficulty breathing, such as shortness of breath or chest tightness, as these symptoms could indicate a potential serious reaction to the medication. Headaches, nervousness, and tremors are common side effects of terbutaline that are less concerning and may not require immediate provider notification unless they become severe or persistent.