Nokea
A nurse midwife is examining a client who is a primigravida at 42 weeks of gestation and states that she believes she is in labor. Which of the following findings confirm to the nurse that the client is in labor
- A. Cervical dilation
- B. Report of pain above the umbilicus
- C. Brownish vaginal discharge
- D. Amniotic fluid in the vaginal vault
Correct Answer: A
Rationale: Cervical dilation is a key physiological change that confirms labor has begun. During the late stages of pregnancy, the cervix starts to soften, thin out (efface), and open up (dilate) in preparation for childbirth. Therefore, cervical dilation is a critical finding that indicates the onset of labor. Pain above the umbilicus, brownish vaginal discharge, and amniotic fluid in the vaginal vault are not definitive signs of labor and do not confirm the initiation of the labor process.
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A nurse is providing teaching to a client who is at 38 weeks of gestation and has a prescription to receive misoprostol intravaginally. Which of the following statement should the nurse make?
- A. "You will need to stay in a side-lying position for 30 minutes after each dose."
- B. "You will receive an IV infusion of oxytocin 1 hour after your last dose."
- C. " You will receive a magnesium supplement immediately following therapy."
- D. " You will need to have a full bladder before the therapy begins."
Correct Answer: A
Rationale: The correct statement the nurse should make to the client receiving misoprostol intravaginally is, "You will need to stay in a side-lying position for 30 minutes after each dose." This instruction is important because maintaining a side-lying position can help prevent leakage and promote proper absorption of the medication. It enhances the effectiveness of the medication and reduces the risk of its expulsion before absorption, ultimately leading to a better response to the treatment. The other options are not relevant to the administration of misoprostol intravaginally and do not align with best practice for this specific therapy.
The nurse is caring for a client in labor with meconium-stained amniotic fluid. What is the priority action?
- A. Administer oxygen to the mother.
- B. Notify the healthcare provider.
- C. Prepare for potential neonatal resuscitation.
- D. Increase IV fluid rate.
Correct Answer: C
Rationale: Meconium-stained amniotic fluid poses a risk of aspiration; preparation for neonatal resuscitation is critical.
The nurse is monitoring a pregnant client with suspected gestational hypertension. What finding confirms the diagnosis?
- A. Proteinuria.
- B. Blood pressure of 140/90 mmHg on two occasions.
- C. Edema of the hands and feet.
- D. Elevated blood glucose levels.
Correct Answer: B
Rationale: Gestational hypertension is diagnosed by consistent readings of 140/90 mmHg or higher without proteinuria.
The newborn's mother is concerned about the shape of the baby's head after delivery. She states that the baby looks like a "cone head." What is the most appropriate response by the nurse?
- A. "You don't need to worry about it. It is perfectly normal after birth."
- B. "It is molding caused by the pressure during birth and will disappear in a few days."
- C. "I will report it to the physician and recommend a diagnostic scan."
- D. "It is a collection of blood related to the trauma of delivery and will absorb in a few weeks.
Correct Answer: B
Rationale: "It is molding caused by the pressure during birth and will disappear in a few days."
A client at 34 weeks' gestation reports regular uterine contractions. What is the nurse's priority action?
- A. Encourage ambulation to relieve discomfort.
- B. Perform a sterile vaginal examination.
- C. Assess fetal heart rate and contraction pattern.
- D. Administer an analgesic as prescribed.
Correct Answer: C
Rationale: Assessing fetal heart rate and contraction pattern is crucial to evaluate for preterm labor.