Nokea
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.
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A primigravida is admitted to the labor area with ruptured membranes and contractions occurring every 2 to 3 minutes, lasting 45 seconds. After 3 hours of labor, the client's contractions are now every 7 to 10 minutes, lasting 30 seconds. The nurse administers oxytocin (Pitocin) as ordered. The expected outcome of this drug is:
- A. The cervix will begin to dilate 2 centimeters per hour.
- B. Contractions will occur every 2 to 3 minutes, lasting 40 to 60 seconds, moderate intensity, resting tone between contractions.
- C. The cervix will change from firm to soft, efface to 40% to 50%, and move from a posterior to anterior position.
- D. Contractions will be every 2 minutes, lasting 60 to 90 seconds, with intrauterine pressure of 70 mm Hg.
Correct Answer: B
Rationale: Oxytocin is used to augment labor by increasing contraction frequency, duration, and intensity. The expected outcome is regular contractions every 2–3 minutes, lasting 40–60 seconds, with moderate intensity and adequate resting tone, promoting effective labor progression. The other options describe unrealistic or unrelated effects.
A 30-year-old woman, G 4, P 4, has delivered a healthy term female neonate by cesarean delivery due to a nonreassuring fetal heart rate tracing. At 2 hours postpartum, the nurse assesses the client's retention catheter and observes that the client's urine is slightly red tinged. Which of the following should the nurse do next?
- A. Continue to monitor the client's input and output.
- B. Massage the client's fundus gently every 15 minutes.
- C. Assess the placement of the retention catheter.
- D. Contact the client's physician for further orders.
Correct Answer: C
Rationale: Red-tinged urine may indicate catheter trauma or misplacement, requiring assessment of catheter placement.
After suction and evacuation of a complete hydatidiform mole, the 28-year-old multigravid client asks the nurse when she can become pregnant again. The nurse would advise the client not to become pregnant again for at least which of the following time spans?
- A. 6 months.
- B. 12 months.
- C. 18 months.
- D. 24 months.
Correct Answer: B
Rationale: Waiting 12 months allows for monitoring for choriocarcinoma.
After instructing a multigravid client at 10 weeks' gestation diagnosed with chronic hypertension about the need for frequent prenatal visits, the nurse determines that the instructions have been successful when the client states which of the following?
- A. "I may develop hyperthyroidism because of my high blood pressure."
- B. "I need close monitoring because I may have a small-for-gestational-age infant."
- C. "It's possible that I will have excess amniotic fluid and may need a cesarean section."
- D. "I may develop placenta accreta, so I need to keep my clinic appointments."
Correct Answer: B
Rationale: Chronic hypertension increases the risk of having a small-for-gestational-age infant.
A primiparous client has just delivered a healthy male infant. The client and her husband are Muslim and the husband begins chanting a song in Arabic while holding the neonate. The nurse interprets the father's actions as indicative of which of the following?
- A. Thanking Allah for giving him a male heir.
- B. Singing to his son from the Koran in praise of Allah.
- C. Expressing appreciation that his wife and son are healthy.
- D. Performing a ritual similar to baptism in other religions.
Correct Answer: D
Rationale: The chanting is likely the Adhan, a Muslim ritual where the call to prayer is recited to the newborn, similar to a baptismal rite.