Nokea
A nurse is preparing a change-of-shift report and has been caring for a multigravid client with a normally progressing labor. Which of the following information should be part of this report? Select all that apply.
- A. Interpretation of the fetal monitor strip.
- B. Analgesia or anesthesia being used.
- C. Anticipated method of birth control.
- D. Amount of vaginal bleeding or discharge.
- E. Support persons with the client.
- F. Prior delivery history.
Correct Answer: A,B,D,E,F
Rationale: A comprehensive shift report includes fetal monitor interpretation, analgesia/anesthesia use, vaginal bleeding/discharge, support persons, and prior delivery history to ensure continuity of care. Anticipated birth control is not relevant during labor.
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The nurse is evaluating the client who delivered vaginally 2 hours ago and is experiencing postpartum pain rated 8 on scale of 1 to 10. The client is a G 4, P 4, breast-feeding mother who would like medication to decrease the pain in her uterus. Which of the medications listed on the orders sheet would be the most appropriate for this client?
- A. Aspirin 1,000 mg P.O. q 4 to 6 hour p.r.n.
- B. Ibuprofen 800 mg P.O. q 6 to 8 hour p.r.n.
- C. Colace 100 mg P.O. b.i.d.
- D. Vicodin 1 to 2 tabs P.O. q 4 to 6 hour p.r.n.
Correct Answer: B
Rationale: Ibuprofen is safe for breastfeeding mothers and effective for uterine cramping pain, unlike aspirin (risk of bleeding), Colace (stool softener), or Vicodin (opioid, less preferred due to sedation risks).
A client is considering the contraceptive implant. Which of the following benefits should the nurse highlight?
- A. It is effective for up to 3 years and reversible.
- B. It provides protection against STIs.
- C. It requires daily administration.
- D. It causes significant weight loss.
Correct Answer: A
Rationale: The contraceptive implant is effective for up to 3 years and is reversible, offering long-term convenience. It does not protect against STIs, require daily administration, or cause significant weight loss.
A primigravid client at 30 weeks' gestation has been admitted to the hospital with premature rupture of the membranes without contractions. Her cervix is 2 cm dilated and 50% effaced. The nurse should next assess the client's:
- A. Red blood cell count.
- B. Degree of discomfort.
- C. Urinary output.
- D. Temperature.
Correct Answer: D
Rationale: Temperature should be assessed to monitor for infection.
A primigravid client at 39 weeks' gestation is admitted to the hospital for induction of labor. The physician has ordered prostaglandin E2 gel (Dinoprostone) for the client. Before administering prostaglandin E2 gel to the client, which of the following should the nurse do first?
- A. Assess the frequency of uterine contractions.
- B. Place the client in a side-lying position.
- C. Determine whether the membranes have ruptured.
- D. Prepare the client for an amniotomy.
Correct Answer: A
Rationale: Prostaglandin E2 gel stimulates contractions, so assessing baseline contraction frequency ensures it is safe to administer (e.g., no hyperstimulation). Membrane status and positioning are secondary, and amniotomy is not required.
When developing the plan of care for a multiparous client in active labor who receives an epidural anesthetic, which of the following would the nurse anticipate that the physician will order if the client develops moderate hypotension?
- A. Ephedrine sulfate.
- B. Epinephrine (Adrenalin Chloride).
- C. Methylergonovine (Methergine).
- D. Atropine sulfate.
Correct Answer: A
Rationale: Ephedrine sulfate is commonly used to treat epidural-related hypotension by increasing blood pressure through vasoconstriction and cardiac stimulation. Epinephrine is for emergencies, methylergonovine treats uterine atony, and atropine addresses bradycardia.