Nokea
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: D
Rationale: The correct answer is D: Descent. At 9 cm dilation, the client is in the second stage of labor, which consists of the descent and birth of the baby. Increasing rectal pressure indicates fetal descent and impending birth. Contractions 2-3 min apart lasting 80-90 seconds are characteristic of the active phase of the second stage of labor. The passive descent phase occurs earlier when the cervix is not fully dilated. The early phase is part of the first stage of labor. Active labor typically begins when the cervix is around 6 cm dilated. Therefore, D is the correct choice as it aligns with the client's symptoms and stage of labor progression.
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A nurse in a prenatal clinic is assessing a group of clients. Which of the following clients should the nurse see first?
- A. A client who is at 11 weeks of gestation and reports abdominal cramping.
- B. A client who is at 15 weeks of gestation and reports tingling and numbness in right hand.
- C. A client who is at 20 weeks of gestation and reports constipation for the past 4 days.
- D. A client who is at 8 weeks of gestation and reports having three bloody noses in the past week.
Correct Answer: A
Rationale: The correct answer is A. Abdominal cramping in early pregnancy could be a sign of an ectopic pregnancy or miscarriage, both of which are urgent and potentially life-threatening conditions. The nurse should prioritize assessing this client to rule out any serious complications.
Choice B is not as urgent as choice A because tingling and numbness in the hand are likely due to musculoskeletal or nerve compression issues, which are not immediately life-threatening.
Choice C, constipation, is a common issue in pregnancy and is not typically considered an urgent concern unless accompanied by severe symptoms like abdominal pain or bleeding.
Choice D, frequent bloody noses, is not typically an urgent concern in early pregnancy unless it is accompanied by other severe symptoms like dizziness or excessive bleeding.
In summary, the nurse should prioritize assessing the client experiencing abdominal cramping at 11 weeks of gestation due to the potential seriousness of this symptom in early pregnancy.
A nurse is assessing a client who is at 30 weeks of gestation during a routine prenatal visit. Which of the following findings should the nurse report to the provider?
- A. Swelling of the face.
- B. Varicose veins in the calves.
- C. Nonpitting 1+ ankle edema.
- D. Hyperpigmentation of the cheeks.
Correct Answer: A
Rationale: The correct answer is A: Swelling of the face. Facial swelling in pregnancy could be a sign of preeclampsia, a serious condition characterized by high blood pressure and protein in the urine. This requires immediate medical attention to prevent complications for both the mother and the baby. Varicose veins in the calves (B) are common in pregnancy but do not pose an immediate threat. Nonpitting 1+ ankle edema (C) is a common finding in pregnancy and typically not concerning unless it worsens. Hyperpigmentation of the cheeks (D) is also a common occurrence during pregnancy known as "the mask of pregnancy" and is not a cause for alarm.
A nurse is teaching a client who is at 35 weeks of gestation about manifestations of potential pregnancy complications to report to the provider. Which of the following manifestations should the nurse include?
- A. Shortness of breath when climbing stairs.
- B. Swelling of feet and ankles at the end of the day.
- C. Headache that is unrelieved by analgesia.
- D. Braxton Hicks contractions.
Correct Answer: C
Rationale: The correct answer is C: Headache that is unrelieved by analgesia. This symptom could indicate a potentially serious condition such as preeclampsia, which requires immediate medical attention to prevent complications for the mother and baby. Shortness of breath when climbing stairs (A) is common in late pregnancy due to the growing uterus pressing on the diaphragm. Swelling of feet and ankles (B) is expected in pregnancy due to increased fluid retention. Braxton Hicks contractions (D) are normal and not a cause for concern unless they become regular and closer together.
A nurse who is caring for a client who is at 15 weeks of gestation, is Rh-negative, and has just had an amniocentesis. Which of the following interventions is the nurse's priority following the procedure?
- A. Check the client's temperature.
- B. Observe for uterine contractions.
- C. Administer Rh(0) Immune globulin.
- D. Monitor the FHR.
Correct Answer: C
Rationale: The correct answer is C: Administer Rh(0) Immune globulin. This is the priority intervention as the client is Rh-negative and has just undergone an invasive procedure like amniocentesis, which carries a risk of fetal-maternal blood transfer. Administering Rh(0) Immune globulin helps prevent the development of Rh incompatibility, which could lead to hemolytic disease in the newborn. Checking the client's temperature (A) and monitoring the FHR (D) are important but not the priority immediately post-procedure. Observing for uterine contractions (B) is important but not the priority for an Rh-negative client after amniocentesis.
The nurse should first implement --- and ---
- A. Providing education on medications.
- B. Administering doxycycline.
- C. Administering ceftriaxone.
- D. Administering metronidazole and educating on condom.
- E. Administering metronidazole.
Correct Answer: B, C
Rationale: The correct answer is B, C. The nurse should first implement administering doxycycline and ceftriaxone in the treatment of certain infections like gonorrhea and chlamydia. Administering these antibiotics promptly is crucial to start the treatment process effectively. Providing education on medications (choice A) can follow once the initial treatment is administered. Administering metronidazole alone (choice E) or with educating on condoms (choice D) is not appropriate for the initial treatment of gonorrhea or chlamydia. Administering metronidazole alone would not effectively address these infections.