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: B
Rationale: The correct answer is B: Active phase. At 9cm dilation, the client is transitioning from the latent phase to the active phase of the first stage of labor. In the active phase, contractions are stronger and more frequent, leading to increased rectal pressure and cervical dilation. This phase typically ranges from 6-10cm dilation. Passive descent (A) refers to the early phase of labor when the cervix is dilating but contractions are mild. Early phase (C) is characterized by 0-3cm dilation. Descent (D) is not a recognized phase of labor. The client's symptoms align with the characteristics of the active phase, making option B the correct choice.
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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 nurse is reviewing the chart of a client who is 2 days postpartum following a vaginal delivery and reports constipation. Which of the following findings should the nurse identify as a contraindication to the use of a suppository?
- A. Vaginal candidiasis
- B. Abdominal distention
- C. Afterpains
- D. Third-degree perineal laceration
Correct Answer: D
Rationale: The correct answer is D: Third-degree perineal laceration. Using a suppository in a client with a third-degree perineal laceration can potentially worsen the injury and increase the risk of infection. The suppository insertion may cause trauma to the already compromised tissue, leading to further complications. It is crucial to avoid any interventions that can exacerbate the injury and hinder the healing process. Choices A, B, and C are not contraindications to using a suppository. Vaginal candidiasis, abdominal distention, and afterpains do not directly impact the safety or effectiveness of using a suppository in this scenario.
A nurse is caring for a client who is at 22 weeks of gestation and is HIV positive. Which of the following actions should the nurse take?
- A. Administer penicillin G 2.4 million units IM to the client.
- B. Instruct the client to schedule an annual pelvic examination.
- C. Tell the client they will start medication for HIV immediately after delivery.
- D. Report the client's condition to the local health department.
Correct Answer: C
Rationale: Correct Answer: C. Tell the client they will start medication for HIV immediately after delivery.
Rationale: Starting HIV medication immediately after delivery is crucial in preventing mother-to-child transmission of HIV. Antiretroviral therapy should be initiated during pregnancy to reduce the viral load and continued postpartum to protect the baby. This approach has been shown to significantly reduce the risk of transmission.
Summary of other choices:
A: Administering penicillin G is not directly related to managing HIV in pregnancy.
B: Annual pelvic examinations are important for overall health but not specific to managing HIV in pregnancy.
D: Reporting the client's condition to the health department may be necessary but does not address the immediate need for HIV medication.
E, F, G: No additional choices provided.
A nurse is assessing a newborn who was born postterm. Which of the following findings should the nurse expect?
- A. Large deposits of subcutaneous fat
- B. Thin covering of fine hair on shoulders and back
- C. Nails extending over tips of fingers
- D. Pale, translucent skin
Correct Answer: C
Rationale: The correct answer is C: Nails extending over tips of fingers. Postterm newborns have longer nails due to the extended intrauterine period. Large deposits of subcutaneous fat (A) are common in term and postterm newborns, not specific to postterm. Thin covering of fine hair on shoulders and back (B) is typical in preterm newborns, not postterm. Pale, translucent skin (D) is seen in preterm infants, not postterm. Therefore, the most appropriate finding to expect in a postterm newborn is nails extending over tips of fingers.
A nurse is caring for a client who is at 20 weeks of gestation and has trichomoniasis. Which of the following findings should the nurse expect?
- A. Thick, white vaginal discharge
- B. Urinary frequency
- C. Vulva lesions
- D. Malodorous discharge
Correct Answer: D
Rationale: The correct answer is D, malodorous discharge. Trichomoniasis is a sexually transmitted infection caused by a parasite, resulting in a foul-smelling, frothy, greenish-yellow vaginal discharge. This discharge is a hallmark symptom of trichomoniasis and is often accompanied by vaginal itching and discomfort. Thick, white discharge (choice A) is more indicative of a yeast infection. Urinary frequency (choice B) is not a typical symptom of trichomoniasis. Vulva lesions (choice C) are more commonly associated with herpes or syphilis. Therefore, based on the client's gestational age and diagnosis, malodorous discharge is the most likely finding.