Nokea
A nurse is caring for a client who is in the transition phase of labor. Which of the following actions should the nurse take?
- A. Assist the client to void every 3 hr
- B. Monitor contractions every 30 min
- C. Place the client into a lithotomy position
- D. Encourage the client to use a pant-blow breathing pattern
Correct Answer: D
Rationale: Encouraging the client to use a pant-blow breathing pattern helps manage pain and anxiety during the transition phase, which is characterized by intense contractions and emotional responses.
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A nurse is assessing a newborn 1 hour after birth. The newborn has acrocyanosis and a heart rate of 130 beats per minute. Which of the following actions should the nurse take?
- A. Place the newborn under a radiant warmer
- B. Apply oxygen
- C. Swaddle the newborn
- D. Reassess the newborn in 1 hour
Correct Answer: D
Rationale: Acrocyanosis, or bluish discoloration of the hands and feet, is a normal finding in newborns in the first few hours after birth. The nurse should continue to monitor the newborn and reassess after some time.
A nurse is caring for a client in active labor who is receiving oxytocin. The nurse notes that the client is experiencing contractions every 1 minute lasting 90 seconds. Which of the following actions should the nurse take?
- A. Stop the oxytocin infusion
- B. Administer oxygen
- C. Increase the IV fluid rate
- D. Prepare for delivery
Correct Answer: A
Rationale: Contractions that are too frequent or prolonged can lead to uterine hyperstimulation, which can compromise fetal oxygenation. The nurse should stop the oxytocin infusion to reduce contraction frequency and intensity.
A home care nurse is following up with a postpartum client. Which of the following is a risk factor that places this client at risk for postpartum depression?
- A. History of anxiety
- B. Socioeconomic status
- C. Hormonal changes with a rapid decline in estrogen and progesterone
- D. Support from family members
Correct Answer: C
Rationale: Postpartum depression can be triggered by various factors, but one of the strongest predictors is a rapid drop in estrogen and progesterone levels following childbirth. These hormonal changes can affect mood regulation, making some women more vulnerable to depression during the postpartum period.
Which of the following characteristics would indicate true labor in a client?
- A. Contractions are irregular and painless
- B. Fetus moves to an anterior position
- C. Bloody show is not present
- D. Contractions are regular in frequency
Correct Answer: D
Rationale: True labor is characterized by regular contractions that increase in intensity and frequency. These contractions result in cervical dilation and effacement, indicating the onset of labor.
A nurse is providing education to a client who is 28 weeks pregnant and at risk for preterm labor. Which of the following signs should the nurse instruct the client to report immediately?
- A. Lower back pain
- B. Shortness of breath
- C. Decreased fetal movement
- D. Nausea and vomiting
Correct Answer: A
Rationale: Lower back pain, especially if accompanied by uterine contractions or pressure, can be a sign of preterm labor. The client should report this immediately to prevent complications or early delivery.