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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 the fetal heart rate (FHR) indicate uteroplacental insufficiency, which could lead to fetal hypoxia. Providing oxygen at 10 L/min via a nonrebreather facemask helps improve oxygenation for both the mother and the fetus. This intervention aims to increase oxygen delivery to the placenta and subsequently improve fetal oxygenation. In contrast, option A (instructing the client to bear down and push with contractions) can further compromise fetal oxygenation. Option C (placing the client in a supine position) can worsen uteroplacental perfusion. Option D (initiating an amnioinfusion) is not indicated for late decelerations and does not address the underlying cause of fetal hypoxia.
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A nurse is preparing to perform Leopold maneuvers on a client who is at 36 weeks of gestation. Identify the sequence of actions the nurse should take.
- A. Instruct the client to empty their bladder.
- B. Position the client supine with knees flexed and place a small, rolled towel under one of their hips.
- C. Palpate the fetal part positioned in the fundus.
- D. Palpate the fetal parts along both sides of the uterus.
Correct Answer: A, B, C, D
Rationale: The correct sequence for performing Leopold maneuvers is A, B, C, D. Firstly, instructing the client to empty their bladder (A) allows for better visualization and palpation of the fetus. Positioning the client supine with knees flexed and a rolled towel under one hip (B) helps relax the abdomen and facilitate palpation. Palpating the fetal part in the fundus (C) helps determine the fetal presentation and position. Finally, palpating the fetal parts along both sides of the uterus (D) aids in assessing the fetal lie and engagement. Choices E, F, and G are not relevant to the correct sequence of Leopold maneuvers.
A nurse is developing a plan of care for a newborn who is to undergo phototherapy for hyperbilirubinemia. Which of the following actions should the nurse include in the plan?
- A. Feed the newborn 1 oz of water every 4 hr.
- B. Apply lotion to the newborn's skin three times per day.
- C. Remove all clothing from the newborn except the diaper.
- D. Discontinue therapy if the newborn develops a rash.
Correct Answer: C
Rationale: The correct answer is C: Remove all clothing from the newborn except the diaper. This is important because phototherapy requires direct exposure of the newborn's skin to the light source to effectively reduce bilirubin levels. Clothing can block the light and decrease the effectiveness of the therapy. It is essential to maximize skin exposure during phototherapy.
Choice A is incorrect because feeding water is not directly related to phototherapy for hyperbilirubinemia. Choice B is incorrect as applying lotion can interfere with the effectiveness of the therapy by creating a barrier between the skin and the light source. Choice D is incorrect because a rash is a common side effect of phototherapy and does not necessarily require discontinuation of the therapy.
A nurse is teaching a client who is at 37 weeks of gestation and has a prescription for a nonstress test. Which of the following instructions should the nurse include?
- A. The test should take 10 to 15 minutes to complete.
- B. You will lay in a supine position throughout the test.
- C. You should not eat or drink for 2 hours before the test.
- D. You should press the handheld button when you feel your baby move.
Correct Answer: D
Rationale: Rationale: The correct answer is D because pressing the handheld button when feeling the baby move helps monitor fetal heart rate and movements during the test. This action allows healthcare providers to assess the baby's well-being. Choice A is incorrect as the test duration varies. Choice B is wrong as the client should lay on their left side, not supine, to prevent compression of the vena cava. Choice C is incorrect as eating and drinking are not restricted before the test.
A nurse is assisting the provider to administer a dinoprostone insert to induce labor for a client. Which of the following actions should the nurse take?
- A. Allow the medication to reach room temperature prior to administration.
- B. Place the client in a semi-Fowler’s position for 1 hr after administration.
- C. Instruct the client to avoid urinary elimination until after administration.
- D. Verify that informed consent is obtained prior to administration.
Correct Answer: D
Rationale: Correct Answer: D - Verify that informed consent is obtained prior to administration.
Rationale: Informed consent is a crucial ethical and legal requirement before any medical procedure. It ensures the client is aware of the risks, benefits, and alternatives to the treatment. Verifying informed consent protects the client's autonomy and prevents potential legal issues.
Incorrect Choices:
A: Allowing the medication to reach room temperature is not necessary for the administration of dinoprostone insert.
B: Placing the client in a semi-Fowler's position after administration is not a standard practice for this procedure.
C: Instructing the client to avoid urinary elimination is unnecessary and could lead to discomfort and potential complications.
E, F, G: No additional choices provided, but they would likely be incorrect as well as they do not address the key safety and ethical considerations associated with administering dinoprostone insert for labor induction.
A nurse is caring for a client who is 12 hr postpartum and has a fourth-degree laceration of the perineum. Which of the following actions should the nurse take?
- A. Apply a moist, warm compress to the perineum.
- B. Provide the client with a cool sitz bath.
- C. Administer methylergonovine 0.2 mg IM.
- D. Apply povidone-iodine to the client’s perineum after she voids.
Correct Answer: A
Rationale: Correct Answer: A. Apply a moist, warm compress to the perineum.
Rationale: Applying a moist, warm compress helps reduce pain, swelling, and discomfort in the perineal area postpartum. It promotes healing and provides comfort to the client with a fourth-degree laceration. This action also helps improve circulation to the area, aiding in the healing process.
Incorrect Choices:
B: Providing a cool sitz bath may provide relief for hemorrhoids or perineal discomfort but is not the best option for a fourth-degree laceration. Warm compresses are more suitable in this situation.
C: Administering methylergonovine is used to prevent or treat postpartum hemorrhage, not for perineal lacerations.
D: Applying povidone-iodine after voiding is not recommended as it can be irritating to the wound and delay healing.