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A nurse is caring for a client who is in labor and requests nonpharmacological pain management. Which of the following nursing actions promotes client comfort?
- A. Assisting the client into squatting position
- B. Having the client lie in a supine position
- C. Applying fundal pressure during contractions
- D. Encouraging the client to void every 6 hr.
Correct Answer: A
Rationale: Assisting the client into a squatting position can help relieve pain and discomfort during labor. Squatting can open up the pelvis, allowing the baby to descend and progress through the birth canal more effectively. This position can also help with gravity-assisted delivery, decreasing the pressure on the mother's back and helping to reduce labor pains. Encouraging various positions during labor can provide comfort and promote optimal positioning for delivery.
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The nurse is monitoring a laboring client with oxytocin infusion. What finding requires immediate intervention?
- A. Contractions lasting 60 seconds.
- B. Contractions every 2 minutes.
- C. Fetal heart rate of 100 beats/minute.
- D. Client reports back pain.
Correct Answer: C
Rationale: A fetal heart rate of 100 bpm indicates bradycardia, requiring immediate intervention to ensure fetal well-being.
The nurse is assessing a client at 20 weeks' gestation with suspected anemia. What lab finding supports this diagnosis?
- A. Hemoglobin of 10 g/dL.
- B. Platelet count of 150,000 mm3.
- C. Hematocrit of 40%.
- D. White blood cell count of 8,000 mm3.
Correct Answer: A
Rationale: A hemoglobin level of 10 g/dL is below normal during pregnancy and indicates anemia.
The woman with the lowest risk for sexually trans-
- A. Red swollen area around distal suture repair of mitted pelvic inflammatory disease is one who uses episiotomy site which of the following?
- B. Oral contraceptives
- C. A barrier method of contraception
- D. An intrauterine device for contraception
Correct Answer: C
Rationale: The lowest risk for sexually transmitted pelvic inflammatory disease is associated with using a barrier method of contraception, such as condoms. Barrier methods create a physical barrier that helps prevent the exchange of bodily fluids, reducing the risk of transmission of sexually transmitted infections, including pelvic inflammatory disease. Oral contraceptives, intrauterine devices, and birth control patches do not provide the same level of protection against sexually transmitted infections as barrier methods like condoms.
A nurse is reviewing the electronic medical record of a postpartum client. The nurse should identify that which of the following factors paces the client at risk for infection.
- A. Meconium "“ start fluid
- B. Placenta previa
- C. Midline episiotomy
- D. Gestational hypertension
Correct Answer: C
Rationale: A midline episiotomy increases the risk for infection in postpartum clients due to the incision made in the perineum during childbirth. This incision can serve as a portal of entry for microorganisms, leading to an increased risk of infection. Meconium-stained amniotic fluid (choice A) can increase the risk of respiratory distress in the newborn but is not directly related to infection in the postpartum client. Placenta previa (choice B) is a condition during pregnancy where the placenta partially or completely covers the cervix, which poses risks related to bleeding rather than infection postpartum. Gestational hypertension (choice D) is a risk factor for developing preeclampsia or eclampsia during pregnancy but does not directly increase the risk of infection in the postpartum period.
The nurse is assessing a client in labor with variable decelerations on the fetal monitor. What is the priority intervention?
- A. Increase oxytocin infusion.
- B. Reposition the client.
- C. Administer oxygen at 10 L/min.
- D. Notify the healthcare provider.
Correct Answer: B
Rationale: Repositioning the client can alleviate umbilical cord compression, the most common cause of variable decelerations.