Nokea
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.
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When caring for a multigravid client admitted to the hospital with vaginal bleeding at 38 weeks' gestation, which of the following would the nurse anticipate administering intravenously if the client develops disseminated intravascular coagulation(DIC)?
- A. Ringer's lactate solution.
- B. Fresh frozen platelets.
- C. 5% dextrose solution.
- D. Warfarin sodium(Coumadin).
Correct Answer: B
Rationale: Fresh frozen platelets are used to manage bleeding in DIC.
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.
The nurse in a postpartum couplet room is making rounds prior to ending the shift. Which of the following indicate that the safety needs of the clients have been met?
- A. Infant lying on abdomen.
- B. Security tags in place.
- C. Identification system on mother and infant.
- D. Bulb syringe within sight.
- E. Someone in room able to care for infant.
- F. Infant in the mother's bed, side rails up.
- G. Infant in the mother's arms, both asleep.
Correct Answer: B,C,D,E
Rationale: Safety needs are met with security tags, identification systems, a bulb syringe for suctioning, and someone present to care for the infant.
The nurse is assessing a client at her postpartum checkup 6 weeks after a vaginal delivery. The mother is bottle feeding her baby. Which client finding indicates a problem at this time?
- A. Firm fundus at the symphysis.
- B. White, thick vaginal discharge.
- C. Striae that are silver in color.
- D. Soft breasts without milk.
Correct Answer: B
Rationale: White, thick vaginal discharge at 6 weeks suggests an infection, as lochia should be minimal or absent by this time.
A primiparous client who is bottle-feeding her neonate at 12 hours after birth asks the nurse, "When will my menstrual cycle return?" Which of the following responses by the nurse would be most appropriate?
- A. Your menstrual cycle will return in 3 to 4 weeks.
- B. It will probably be 6 to 10 weeks before it starts again.
- C. You can expect your menses to start in 12 to 14 weeks.
- D. Your menses will return in 16 to 18 weeks.
Correct Answer: B
Rationale: For bottle-feeding mothers, menstruation typically resumes 6 to 10 weeks postpartum due to the absence of breastfeeding's hormonal suppression.