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Client receiving opioid epidural analgesia during labor
A nurse is caring for a client who is receiving opioid epidural analgesia during labor. Which of the following findings is the nurse's priority?
- A. Blood pressure 80/56 mm Hg.
- B. The client reports profuse itching.
- C. The client reports weakness of the lower extremities.
- D. Temperature 38.2°C (100.8 F).
Correct Answer: A
Rationale: Hypotension (80/56 mm Hg) is the priority as it can reduce placental blood flow, risking fetal distress, and requires immediate intervention.
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Newborn immediately after birth
The priority nursing care of the newborn immediately after birth includes all except:
- A. Support thermoregulation.
- B. Identify the infant.
- C. Promote normal respirations.
- D. Announcement of the delivery.
Correct Answer: D
Rationale: Announcement of the delivery is not a priority in nursing care of the newborn immediately after birth. While it may be a joyful moment for the parents and family, it does not affect the health and well-being of the newborn. Therefore, it can be done later after the essential newborn care has been completed.
Woman in labor, vacuum extraction
A maternal indication for the use of vacuum extraction is
- A. Maternal exhaustion.
- B. Failure to progress past 0 station.
- C. A wide pelvic outlet.
- D. A history of rapid deliveries.
Correct Answer: A
Rationale: Maternal exhaustion indicates vacuum extraction to assist delivery when the mother cannot push effectively, reducing fatigue and distress.
During vaginal delivery, newborn's head emerges
During a vaginal delivery, the first thing a nurse must ensure when the head comes out is that the midwife or doctor checks that
- A. The cord is still pulsating.
- B. The cord is intact.
- C. No part of the cord is encircling the baby's neck.
- D. The cord is still attached to the placenta.
Correct Answer: C
Rationale: Checking for a nuchal cord (cord around the neck) is critical to prevent compression, which could reduce blood flow and oxygen to the baby.
Woman receiving oxytocin (Pitocin) infusion
For which patient should the oxytocin (Pitocin) infusion be discontinued immediately?
- A. A woman in early labor with contractions every 5 minutes lasting 40 seconds each.
- B. A woman in active labor with contractions every 30 minutes lasting 60 seconds each.
- C. A woman in active labor with contractions every 2 to 3 minutes lasting 70 to 80 seconds each.
- D. A woman in transition with contractions every 1.5 minutes lasting 95 seconds each.
Correct Answer: D
Rationale: Contractions every 1.5 minutes lasting 95 seconds in transition indicate hyperstimulation, risking fetal distress, so the infusion should be stopped.
Infant being weighed
The correct answer is choice A, which is to ensure that conductive heat loss from the infant is minimal
- A. ensure that conductive heat loss from the infant is minimal
- B. compensate for the negative weight balance to ensure the correct weight
- C. avoid causing multiple startle (Moro) reflexes when weighing
- D. avoid contaminating the nurse's hands with blood or other body substances
Correct Answer: A
Rationale: A covering on the scale tray minimizes conductive heat loss by preventing direct contact with the cold scale surface, critical for maintaining the infant's temperature.