Nokea
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?" This question is crucial because the occipitoposterior position can cause intense back pain during labor. By asking if the back labor has improved, the nurse can assess the effectiveness of the hands-and-knees position in helping relieve the client's discomfort. A: "Does that lessen your suprapubic pain?" is incorrect because suprapubic pain is not specifically associated with occipitoposterior positioning. B: "Are you feeling relief from your pelvic pressure?" is incorrect as it does not directly address the back pain associated with occipitoposterior positioning. C: "Do your contractions feel further apart?" is incorrect as it does not focus on the back pain issue. The key is to address the specific discomfort caused by the occipitoposterior position.
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A nurse is reviewing the medical record of a client who had a vaginal delivery 3 hr ago. Which of the following findings place the client at risk for postpartum hemorrhage? (Select all that apply.)
- A. Labor induction with oxytocin
- B. Newborn weight 2.948 kg (6 lb 8 oz)
- C. Vacuum-assisted delivery
- D. History of uterine atony
- E. History of human papillomavirus
Correct Answer: A,C,D
Rationale: The correct answers are A, C, and D.
A: Labor induction with oxytocin can lead to uterine hyperstimulation, increasing the risk of postpartum hemorrhage.
C: Vacuum-assisted delivery can cause trauma to the birth canal, leading to increased bleeding.
D: History of uterine atony indicates a potential inability of the uterus to contract effectively, increasing the risk of postpartum hemorrhage.
B: Newborn weight and history of human papillomavirus are not directly related to postpartum hemorrhage.
A nurse is caring for a client who is receiving an epidural block with an opioid analgesic. The nurse should monitor for which of the following findings as an adverse effect of the medication?
- A. Hyperglycemia
- B. Bilateral crackles
- C. Hypotension
- D. Polyuria
Correct Answer: C
Rationale: The correct answer is C: Hypotension. Opioid analgesics can cause vasodilation, leading to a drop in blood pressure. The nurse should monitor for hypotension as a potential adverse effect, as this can result in dizziness and decreased perfusion. Hyperglycemia (A) is not typically associated with opioid analgesics. Bilateral crackles (B) are more indicative of fluid overload or pulmonary edema. Polyuria (D) is excessive urination and is not a common adverse effect of opioid analgesics.
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 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 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 known to cause breast tenderness as a common adverse effect due to its estrogen-like effects. This occurs because clomiphene citrate can increase estrogen levels in the body, leading to breast discomfort. Tinnitus (B), urinary frequency (C), and chills (D) are not typically associated with clomiphene citrate use. Tinnitus is more commonly linked to ototoxic medications, urinary frequency may occur with diuretics, and chills are often seen with infections or febrile illnesses. Therefore, the nurse should emphasize breast tenderness as a potential side effect of clomiphene citrate to the client.