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 9 cm dilation, the client is in the active phase of the first stage of labor. This phase is characterized by more rapid cervical dilation (6-10 cm) and increased contractions with shorter intervals. The client's symptoms align with this phase as they are experiencing strong contractions close together, along with increased rectal pressure indicating descent of the fetus. Other choices are incorrect as: A (Passive descent) occurs during the second stage of labor; C (Early phase) is typically before 6 cm dilation; D (Descent) is not a recognized phase of labor.
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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 preeclampsia, a serious pregnancy complication characterized by high blood pressure and organ damage. Prompt reporting is crucial to prevent complications. Shortness of breath (A) and swelling of feet and ankles (B) are common in pregnancy but not necessarily indicative of a serious complication. Braxton Hicks contractions (D) are normal and not usually a cause for concern.
Which of the following indicates whether the adolescent understands the teaching on requires further education?
- A. I should continue taking all my medications even if I don't show any symptoms.
- B. If I continue to get this type of infection, it can affect my ability to have kids in the future.
- C. I should go to the emergency department if my urine turns dark.
- D. As long as I keep my IUD, I don't need to use condoms.
- E. I'm more likely to get a sunburn while taking these medications.
Correct Answer: D
Rationale: Step-by-step rationale for why answer D is correct:
1. Choice D states, "As long as I keep my IUD, I don't need to use condoms." This statement indicates a misunderstanding as IUDs do not protect against sexually transmitted infections .
2. This statement shows a lack of understanding regarding the importance of using condoms to prevent STIs.
3. Therefore, selecting Choice D indicates that further education is required to clarify the misconception about the role of IUDs in STI prevention.
Summary:
- Choice A is correct as it indicates a misunderstanding about the necessity of taking medications regardless of symptoms.
- Choice B is correct as it states a potential consequence of untreated infections, showing understanding.
- Choice C is correct as it highlights a symptom that warrants immediate medical attention.
- Choice E is incorrect as it does not pertain to the understanding of contraception and STI prevention.
- Choices F and G are not applicable and can be disregarded.
A nurse is caring for a newborn who is experiencing neonatal abstinence syndrome. Which of the following actions should the nurse take?
- A. Decrease the lighting levels in the nursery.
- B. Wrap the newborn loosely in a blanket.
- C. Provide frequent stimulation for the newborn.
- D. Encourage frequent eye contact with the newborn during feedings
Correct Answer: A
Rationale: The correct answer is A: Decrease the lighting levels in the nursery. Neonatal abstinence syndrome causes sensitivity to stimuli, including light. By decreasing lighting levels, the nurse can help reduce overstimulation and promote a calm environment for the newborn. This can aid in soothing the baby and decreasing symptoms associated with the syndrome.
Choice B is incorrect because wrapping the newborn loosely in a blanket may not directly address the sensitivity to light and other stimuli. Choice C, providing frequent stimulation, would likely exacerbate the symptoms of neonatal abstinence syndrome due to the increased sensory input. Choice D, encouraging frequent eye contact during feedings, could also lead to overstimulation for the newborn.
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, potentially leading to fetal distress. Oxytocin can further stress the fetus by increasing uterine contractions, exacerbating the late decelerations. Late decelerations are a sign of decreased oxygen supply to the fetus, making it unsafe to augment labor with oxytocin. Therefore, this finding should be reported to the provider to ensure the safety of both the client and the fetus.
Incorrect choices:
B: Moderate variability of the FHR is a reassuring sign of fetal well-being, not a contraindication for oxytocin infusion.
C: Cessation of uterine dilation may indicate a stalled labor progress but is not a contraindication for initiating oxytocin.
D: Prolonged active phase of labor may warrant augmentation with oxytocin rather than being a contraindication.
A nurse is caring for a client who has preeclampsia and is receiving a continuous infusion of magnesium sulfate IV. Which of the following actions should the nurse take?
- A. Restrict hourly fluid intake to 150 mL/hr.
- B. Have calcium gluconate readily available.
- C. Assess deep tendon reflexes every 6 hr.
- D. Monitor intake and output every 4 hr.
Correct Answer: B
Rationale: The correct answer is B: Have calcium gluconate readily available. Magnesium sulfate can lead to magnesium toxicity, causing respiratory depression and cardiac arrest. Calcium gluconate is the antidote for magnesium toxicity, so having it readily available is crucial for immediate administration if toxicity occurs. Option A is incorrect as fluid intake should not be restricted in preeclampsia. Option C is incorrect as deep tendon reflexes should be assessed more frequently (every 1-2 hours) due to the risk of hypermagnesemia. Option D is incorrect as intake and output should be monitored hourly to detect any changes in renal function.