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A nurse is caring for a client who is receiving oxytocin to augment labor. The nurse notes recurrent variable decelerations...Which of the following actions should the nurse take first?
- A. Prepare the equipment necessary to initiate an amnioinfusion.
- B. Administer oxygen at 10 L/min via nonrebreather face mask.
- C. Discontinue the infusion of oxytocin.
- D. Place the client in a left lateral position.
Correct Answer: C
Rationale: Recurrent variable decelerations during labor can indicate umbilical cord compression, which can result in fetal hypoxia and distress. Discontinuing the oxytocin infusion is the priority in this situation as oxytocin can cause or exacerbate uteroplacental insufficiency leading to fetal distress. By discontinuing the oxytocin, the nurse can help improve fetal oxygenation and alleviate the variable decelerations. After stopping the oxytocin infusion, the nurse should continue to monitor the fetal heart rate pattern and follow the healthcare provider's orders for further management if needed.
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After her baby's birth a patient wishes to begin breastfeeding. The nurse assists the client by:
- A. Positioning the infant to grasp the nipple to express milk.
- B. Giving the infant a bottle first to evaluate the baby's ability to suck
- C. Leaving them alone and allowing the infant to nurse as long as desired
- D. Touching the infant's cheek adjacent to the nipple to elicit the rooting reflex
Correct Answer: A
Rationale: Positioning the infant to grasp the nipple to express milk is an essential step in helping the patient begin breastfeeding successfully. As a nurse, it is crucial to ensure that the infant is properly latched onto the breast to facilitate effective feeding and milk transfer. This involves positioning the infant in a way that allows them to effectively grasp the nipple, promoting proper suckling and milk production. By assisting the patient in positioning the infant correctly, the nurse is supporting the establishment of successful breastfeeding and ensuring optimal nutrition for the baby.
A nurse is caring for a client who is gravida 3, para 2, and is in active labor. The fetal head is at 3+ station after a vaginal examination. Which of the following actions should the nurse take
- A. Apply fundal pressure.
- B. Observe for the presence of a nuchal cord.
- C. Observe for crowning.
- D. Prepare to administer oxytocin.
Correct Answer: C
Rationale: Observing for crowning is the appropriate action for the nurse to take when the fetal head is at 3+ station after a vaginal examination. Crowning refers to the appearance of the baby's head at the vaginal opening during delivery. This indicates that the baby is descending and will be born soon. It is important for the nurse to be prepared for the actual birth once crowning is observed, as it signifies that the second stage of labor is progressing and delivery is imminent. Applying fundal pressure, observing for a nuchal cord, or preparing to administer oxytocin are not appropriate actions at this stage of labor when crowning has been observed.
The nurse is performing an assessment of a postpartum client. Which finding requires immediate action?
- A. Temperature of 100.4°F.
- B. Foul-smelling lochia.
- C. Fundus firm and midline.
- D. Breast tenderness on palpation.
Correct Answer: B
Rationale: Foul-smelling lochia may indicate an infection and requires prompt medical evaluation.
A patient who has an LNG-IUC in place calls the office and states she just took a pregnancy test, and it is positive. She comes in for a visit, and the nurse does another pregnancy test, which is positive. What does the nurse know that the clinician will inform the patient regarding the IUC?
- A. Removing the IUC may increase the chance of infertility.
- B. The fetus is at risk for congenital defects.
- C. The IUC needs to be removed regardless of the plans for this pregnancy.
- D. There is no risk to the fetus if the IUC is left in place.
Correct Answer: D
Rationale: The correct statement the nurse knows that the clinician will inform the patient regarding the LNG-IUC is that there is no risk to the fetus if the IUC is left in place. The LNG-IUC (levonorgestrel-releasing intrauterine system) is a highly effective form of contraception that works by releasing progesterone locally in the uterus. The hormonal effect of the LNG-IUC is mostly limited to the uterus and very little of it circulates systemically. Therefore, there is no known increased risk of congenital defects or harm to the fetus if the IUC is left in place during pregnancy. The IUC can be left in place if the patient chooses to continue the pregnancy, provided there are no signs of infection or other complications that would necessitate its removal.
The nurse is performing Leopold's maneuvers on a client in labor. What is the primary purpose of this assessment?
- A. Evaluate fetal heart rate.
- B. Determine fetal position and presentation.
- C. Check for uterine contractions.
- D. Assess amniotic fluid volume.
Correct Answer: B
Rationale: Leopold's maneuvers help identify fetal position, presentation, and engagement for labor management.