Nokea
A primigravid client in active labor with a fetus in LOP position complains of severe back pressure. Which of the following would be the priority nursing diagnosis for this client?
- A. Anxiety related to fear of maternal-fetal outcomes.
- B. Ineffective coping related to lack of experience in labor.
- C. Urinary retention related to prolonged labor process.
- D. Pain related to occipitoposterior position and prolonged fetal descent.
Correct Answer: D
Rationale: Severe back pain due to the LOP position is a priority, as it impacts the client's comfort and labor experience. Pain management (e.g., counterpressure) is critical. Anxiety, coping, and urinary retention are secondary concerns.
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A multigravid client is admitted to the hospital with a diagnosis of ectopic pregnancy. The nurse anticipates that, because the client's fallopian tube has not yet ruptured, which of the following may be ordered?
- A. Progestin contraceptives(Hylutin).
- B. Medroxyprogesterone(Depo-Provera).
- C. Methotrexate.
- D. Dyphylline(Dilor).
Correct Answer: C
Rationale: Methotrexate is used to treat unruptured ectopic pregnancies.
The physician orders an amnioinfusion for a primigravid client at term who is diagnosed with oligohydramnios. Which of the following should the nurse include in the client's teaching plan about the purpose of this procedure?
- A. To decrease the frequency and severity of variable decelerations.
- B. To minimize the possibility of fetal metabolic alkalosis.
- C. To increase the fetal heart rate accelerations during a contraction.
- D. To raise the amniotic fluid index to more than 15 cm.
Correct Answer: A
Rationale: Amnioinfusion replaces amniotic fluid in oligohydramnios, reducing cord compression and the frequency/severity of variable decelerations. It does not affect metabolic alkalosis, heart rate accelerations, or guarantee a specific fluid index.
A primiparous client who underwent a cesarean delivery 30 minutes ago is to receive Rho(D) immune globulin (RhoGAM). The nurse should administer the medication within which of the following time frames after delivery?
- A. 8 hours.
- B. 24 hours.
- C. 72 hours.
- D. 96 hours.
Correct Answer: C
Rationale: RhoGAM should be administered within 72 hours postpartum to prevent Rh sensitization.
The labor and delivery unit is short-staffed, and the charge nurse must prioritize assignments. Which client should the registered nurse personally assess first?
- A. A primigravida at 4 cm dilation requesting pain relief.
- B. A multigravida at 8 cm dilation with a history of rapid labors.
- C. A primigravida with stable vital signs post-epidural.
- D. A multigravida at 6 cm dilation with a reassuring fetal monitor.
Correct Answer: B
Rationale: A multigravida at 8 cm dilation with a history of rapid labors is at risk for precipitous delivery, requiring immediate RN assessment to prepare for birth. Other clients are less urgent, as they are earlier in labor or stable.
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.