Nokea
A primigravid client at 39 weeks' gestation is admitted in early labor with contractions every 6 minutes. The nurse notes a fetal heart rate of 145 bpm with occasional variable decelerations. What is the nurse's first action?
- A. Notify the physician immediately.
- B. Administer oxygen via non-rebreather mask.
- C. Reposition the client to her left side.
- D. Increase the IV fluid rate.
Correct Answer: C
Rationale: Variable decelerations may indicate umbilical cord compression. Repositioning the client to her left side is the first action to relieve pressure on the cord and improve fetal oxygenation. Notification, oxygen, or increased fluids are considered if decelerations persist.
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Which of the following would the nurse include in the teaching plan for a 16-year-old primigravid client in early labor concerning active relaxation techniques to help her cope with pain?
- A. Relaxing uninvolved body muscles during uterine contractions.
- B. Practicing being in a deep, meditative, sleeplike state.
- C. Focusing on an object in the room during the contractions.
- D. Breathing rapidly and deeply between contractions.
Correct Answer: A
Rationale: Active relaxation involves consciously relaxing uninvolved muscles (e.g., face, arms) during contractions to conserve energy and reduce tension, aiding pain management. Meditation is less practical during active labor, focusing on an object is a distraction technique, and rapid breathing between contractions may cause hyperventilation.
A primigravid client at 39 weeks' gestation is admitted to the hospital in active labor. On admission, the client's cervix is 6 cm dilated. After 2 hours of active labor, the client's cervix is still dilated at 6 cm with 100% effacement at -1 station. Contractions are 3 to 5 minutes apart, lasting 45 seconds, and of moderate intensity. The nurse determines that the client is most likely experiencing which of the following?
- A. Cephalopelvic disproportion.
- B. Prolonged latent phase.
- C. Prolonged transitional phase.
- D. Hypotonic contraction pattern.
Correct Answer: A
Rationale: Lack of cervical dilation (6 cm after 2 hours) despite adequate contractions suggests cephalopelvic disproportion, where the fetal head cannot pass through the pelvis. Prolonged latent phase occurs earlier, transition is at 8–10 cm, and hypotonic contractions are weaker.
A newborn with a cleft palate at 1 hour of life has a nursing diagnosis of Risk for Infection related to potential aspiration during feedings. Which of the following nursing actions would support the best feeding practice for this infant?
- A. Use an appropriate nipple and bottle set.
- B. Encourage the mother to breast-feed.
- C. Assess daily weights and wet diapers to monitor intake.
- D. Allow unlimited length of time for each feeding.
Correct Answer: A
Rationale: Using an appropriate nipple and bottle set designed for cleft palate infants minimizes aspiration risk during feedings.
A client is considering the fertility awareness method. Which of the following client statements indicates understanding?
- A. I will track my basal body temperature daily.
- B. I can use this method with irregular cycles.
- C. I will monitor ovulation with a pregnancy test.
- D. I will avoid intercourse throughout the cycle.
Correct Answer: A
Rationale: Tracking basal body temperature daily is a key component of the fertility awareness method. It is less reliable with irregular cycles, pregnancy tests do not monitor ovulation, and intercourse is avoided only during fertile periods.
The nurse is caring for a primipara in active labor when the fetus develops severe bradycardia with late decelerations, and an emergency cesarean delivery is performed with the client under general anesthesia. After the delivery, the client tells the nurse, 'I feel terrible. This is exactly what I didn't want to happen!' Which of the following is a priority nursing diagnosis for this client?
- A. Interrupted family processes related to cesarean delivery.
- B. Anxiety related to incisional scar and neonatal outcome.
- C. Pain related to surgical incision and uterine cramping.
- D. Situational low self-esteem related to inability to deliver vaginally.
Correct Answer: D
Rationale: The client's statement reflects disappointment and possible feelings of failure due to the unplanned cesarean, making situational low self-esteem the priority. Pain, anxiety, and family processes are secondary concerns post-delivery.