Nokea
A nurse is caring for a client who is in the second stage of labor and is experiencing a shoulder dystocia. The provider instructs the nurse to perform the McRoberts maneuver. Which of the following actions should the nurse take?
- A. Apply pressure to the client's fundus.
- B. Press firmly on the client’s suprapubic area.
- C. Move the client onto their hands and knees.
- D. Assist the client in pulling their knees toward their abdomen.
Correct Answer: D
Rationale: The correct answer is D: Assist the client in pulling their knees toward their abdomen. In shoulder dystocia, the McRoberts maneuver involves hyperflexing the mother's legs against her abdomen. This action helps to widen the pelvic outlet and reduce the angle of the pubic symphysis, facilitating the delivery of the infant's shoulder. Pressing on the fundus (A) does not address the shoulder dystocia issue. Pressing on the suprapubic area (B) may not provide the necessary assistance in this situation. Moving the client onto their hands and knees (C) does not facilitate the specific maneuver required. Therefore, assisting the client in pulling their knees toward their abdomen (D) is the correct action in this scenario.
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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, leading to a foul-smelling vaginal discharge. At 20 weeks of gestation, the nurse should expect this symptom due to the infection. Thick, white vaginal discharge (choice A) is more indicative of a yeast infection. Urinary frequency (choice B) is not typically associated with trichomoniasis. Vulva lesions (choice C) are more commonly seen in herpes infection. Therefore, the malodorous discharge (choice D) aligns with the expected finding in a client with trichomoniasis at 20 weeks of gestation.
A nurse manager on the labor and delivery unit is teaching a group of newly licensed nurses about maternal cytomegalovirus. Which of the following information should the nurse manager include in the teaching?
- A. Mothers will receive prophylactic treatment with acyclovir prior to delivery.
- B. Transmission can occur via the saliva and urine of the newborn.
- C. Lesions are visible on the mother’s genitalia.
- D. This infection requires that airborne precautions be initiated for the newborn.
Correct Answer: B
Rationale: The correct answer is B: Transmission can occur via the saliva and urine of the newborn. Maternal cytomegalovirus can be transmitted to the newborn through contact with infected bodily fluids such as saliva and urine. This is important for the nurses to understand as they care for both the mother and the newborn to prevent transmission.
Choice A is incorrect because acyclovir is not used to treat cytomegalovirus, but rather for other viral infections like herpes. Choice C is incorrect because lesions are not typically visible on the mother's genitalia with cytomegalovirus. Choice D is incorrect because airborne precautions are not necessary for cytomegalovirus transmission.
A nurse is caring for a client who is receiving oxytocin via continuous IV infusion and is experiencing persistent late decelerations in the FHR. After discontinuing the infusion, which of the following actions should the nurse take?
- A. Instruct the client to bear down and push with contractions.
- B. Administer oxygen at 10 L/min via nonrebreather facemask.
- C. Place the client in a supine position.
- D. Initiate an amnioinfusion.
Correct Answer: B
Rationale: The correct answer is B: Administer oxygen at 10 L/min via nonrebreather facemask. Late decelerations in fetal heart rate (FHR) indicate uteroplacental insufficiency, possibly due to decreased oxygen supply to the fetus. Providing oxygen to the mother increases oxygen delivery to the fetus, improving oxygenation and potentially reversing the late decelerations. Other choices are incorrect: A could increase intra-abdominal pressure, worsening late decelerations. C can decrease placental perfusion. D is not indicated for late decelerations.
A nurse is assessing a newborn whose mother had gestational diabetes mellitus. The nurse should monitor for which of the following findings as a manifestation of hypoglycemia?
- A. Abdominal distention
- B. Petechiae
- C. Increased muscle tone
- D. Jitteriness
Correct Answer: D
Rationale: The correct answer is D: Jitteriness. Neonates born to mothers with gestational diabetes are at risk for hypoglycemia due to the abrupt cessation of the maternal glucose supply postnatally. Jitteriness is a common manifestation of hypoglycemia in newborns. It is important for the nurse to monitor for this sign as it indicates the need for prompt intervention to prevent further complications. Abdominal distention, petechiae, and increased muscle tone are not typically associated with hypoglycemia in newborns born to mothers with gestational diabetes.
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 a medication commonly used to treat infertility by stimulating ovulation. Breast tenderness is a common side effect due to the hormonal changes it induces, as it can lead to increased estrogen levels. This is important for the nurse to include in teaching as it prepares the client for a potential adverse effect.
B: Tinnitus, C: Urinary frequency, D: Chills are not typically associated with clomiphene citrate use. Tinnitus is more commonly linked to ototoxic medications, urinary frequency is not a known side effect of clomiphene, and chills are not a typical reaction to this medication. It is essential for the nurse to focus on the most relevant and common adverse effects to ensure the client's understanding and safety.