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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Which of the following would lead the nurse to suspect retinopathy of prematurity (ROP) when assessing a neonate at 32 weeks' gestation who weighs 2,000 g ?
- A. Sunken orbital sockets.
- B. Strabismus.
- C. Reaction to bright light.
- D. Constricted retinal vessels.
Correct Answer: D
Rationale: Constricted retinal vessels are a sign of ROP, indicating abnormal retinal vascular development.
One week after her prenatal visit, a primigravid client at 38 weeks' gestation diagnosed with mild preeclampsia calls the clinic nurse complaining of a continuous headache for the past 2 days accompanied by nausea. The client does not want to take aspirin. The nurse should tell the client:
- A. "Take two acetaminophen tablets. They aren't as likely to upset your stomach."
- B. "I think the doctor should see you today. Can you come to the clinic this morning?"
- C. "You need to lie down and rest. Have you tried placing a cool compress over your head?"
- D. "I'll ask the doctor to call in a prescription for aspirin with codeine. What's your pharmacy's number?"
Correct Answer: B
Rationale: Continuous headache and nausea are signs of worsening preeclampsia requiring evaluation.
During an assessment of a neonate born at 33 weeks' gestation, a nurse finds and reports a heart murmur. The neonate is diagnosed with patent ductus arteriosus, for which the neonate received indomethacin. An expected outcome after the administration of indomethacin to a neonate with patent ductus arteriosus is:
- A. Closure of a patent ductus arteriosus.
- B. Decreased bleeding time.
- C. Increased gastrointestinal function.
- D. Increased renal output.
Correct Answer: A
Rationale: Indomethacin promotes closure of the patent ductus arteriosus by inhibiting prostaglandin synthesis.
A client is considering the withdrawal method. Which of the following statements by the nurse is accurate?
- A. The withdrawal method is highly effective with perfect use.
- B. The withdrawal method has a high failure rate and does not protect against STIs.
- C. The withdrawal method requires a prescription.
- D. The withdrawal method is more effective than oral contraceptives.
Correct Answer: B
Rationale: The withdrawal method has a high failure rate due to pre-ejaculate and timing issues and does not protect against STIs. It does not require a prescription and is less effective than oral contraceptives.
While assessing a neonate weighing 3,175 g (7 lb) who was born at 39 weeks' gestation to a primiparous client who admits to cocaine use during pregnancy, which of the following would alert the nurse to possible cocaine withdrawal?
- A. Bradycardia.
- B. High-pitched cry.
- C. Sluggishness.
- D. Hypocalcemia.
Correct Answer: B
Rationale: A high-pitched cry is a common sign of cocaine withdrawal in neonates, indicating neurological irritability.