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Client using an intrauterine device (IUD) for contraception.
A nurse is teaching a client about using an intrauterine device (IUD) for contraception. Which of the following client statements indicates an understanding of the teaching?
- A. I will need to have the IUD replaced each year.
- B. I will need to apply a spermicide prior to intercourse.
- C. I should expect my periods to stop while I have the IUD.
- D. I should check for the string each month after menstruation.
Correct Answer: D
Rationale: Checking for the string ensures proper IUD positioning and functionality. This monthly practice helps detect dislodgement or expulsion, which can compromise contraceptive effectiveness.
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Client at 34 weeks of gestation scheduled for a nonstress test.
A nurse is providing teaching to a client who is at 34 weeks of gestation and is scheduled for a nonstress test. Which of the following statements should the nurse plan to make?
- A. You will receive a medication through an IV for this test.
- B. You should expect the test to take about 30 minutes.
- C. You should not eat or drink for 4 hours prior to the test.
- D. This test will help determine if your baby's lungs are mature.
Correct Answer: B
Rationale: Nonstress tests typically last about 20–40 minutes, depending on fetal activity and reactivity. This duration allows sufficient time to observe fetal heart rate accelerations.
Client receiving oxytocin to augment labor, nurse notes recurrent variable decelerations of the FHR.
A nurse is caring for a client who is receiving oxytocin to augment labor. The nurse notes recurrent variable decelerations of the FHR. Which of the following actions should the nurse take first?
- A. Prepare the necessary equipment to initiate an amnioinfusion.
- B. Assist with performing a vaginal/speculum exam to check for a prolapsed umbilical cord.
- C. Discontinue the infusion of oxytocin.
- D. Provide instructions for the client about potential preparation for birth.
Correct Answer: C
Rationale: Discontinuing oxytocin reduces uterine contractions, alleviating cord compression and improving fetal oxygenation, which is the first step in managing recurrent variable decelerations of fetal heart rate.
Newborn who is 48 hr old with a maternal history of methadone use during pregnancy.
A nurse is assessing a newborn who is 48 hr old and has a maternal history of methadone use during pregnancy. Which of the following manifestations should the nurse identify as an indication of neonatal abstinence syndrome?
- A. Hyporeactivity.
- B. Excessive high-pitched cry.
- C. Acrocyanosis.
- D. Respiratory rate of 50/min.
Correct Answer: B
Rationale: Excessive high-pitched crying results from central nervous system hyperirritability caused by withdrawal. Neonatal abstinence syndrome involves exaggerated responses to stimuli, reflecting the neonate's difficulty in self-regulation.
Client has been pushing for 2.5 hours with minimal progress, fetal head remains at +2 station.
A nurse in the labor and delivery triage unit assesses a client who has been pushing for 2.5 hours with minimal progress. The fetal head remains at +2 station. Which of the following is the most appropriate next action?
- A. Perform a vaginal exam to reassess effacement and dilation.
- B. Notify the primary health care provider about minimal progress.
- C. Prepare the client for vacuum-assisted delivery.
- D. Administer intravenous oxytocin.
Correct Answer: B
Rationale: Notifying the primary health care provider about minimal progress is the most appropriate next action. The client has been pushing for 2.5 hours with minimal progress, which raises concern for potential complications such as cephalopelvic disproportion or maternal exhaustion.
Client reporting severe abdominal pain.
A nurse in the labor and delivery triage unit reviews the electronic medical record (EMR) of a client reporting severe abdominal pain. Which of the following findings is most consistent with abruptio placenta?
- A. Low uterine tone with mild vaginal bleeding.
- B. Rigid uterine tone with dark vaginal bleeding.
- C. Soft uterine tone with painless vaginal bleeding.
- D. Low uterine tone with absence of vaginal bleeding.
Correct Answer: B
Rationale: Rigid uterine tone with dark vaginal bleeding is a hallmark of abruptio placenta. The rigidity arises from blood pooling behind the placenta, causing uterine muscle contraction. Dark vaginal bleeding occurs as the blood is often concealed and clotted before expulsion.