Nokea
A primigravid client is admitted as an outpatient for an external cephalic version. The nurse should assess the client for which of the following contraindications for the procedure?
- A. Multiple gestation.
- B. Breech presentation.
- C. Maternal Rh-negative blood type.
- D. History of gestational diabetes.
Correct Answer: A
Rationale: External cephalic version (ECV) is contraindicated in multiple gestation due to the risk of cord entanglement or placental issues. Breech presentation is an indication for ECV, not a contraindication. Rh-negative blood type and gestational diabetes do not preclude ECV.
You may also like to solve these questions
The cervix of a primigravid client in active labor who received epidural anesthesia 4 hours ago is now completely dilated, and the client is ready to begin pushing. Before the client begins to push, the nurse should assess:
- A. Fetal heart rate variability.
- B. Cervical dilation again.
- C. Status of membranes.
- D. Bladder status.
Correct Answer: D
Rationale: A full bladder can impede fetal descent and increase discomfort during pushing. Assessing bladder status (and catheterizing if needed) is critical before pushing begins. Fetal heart rate, dilation, and membrane status should already be monitored but are not the priority at this moment.
Following an epidural and placement of internal monitors, a client's labor is augmented. Contractions are lasting greater than 90 seconds and occurring every 1½ minutes. The uterine resting tone is greater than 20 mm mercury with a nonreassuring fetal heart rate and pattern. Which of the following actions should the nurse take first?
- A. Notify the health care provider.
- B. Turn off the oxytocin (Pitocin) infusion.
- C. Turn the client to her left side.
- D. Increase the maintenance I.V. fluids.
Correct Answer: B
Rationale: Hyperstimulation (contractions >90 seconds, frequent, with high resting tone) and nonreassuring fetal heart rate indicate fetal distress. Stopping oxytocin is the first step to reduce uterine activity and improve fetal oxygenation. Repositioning, notifying the provider, or increasing fluids follow.
Which of the following would the nurse expect to assess in a neonate delivered at 28 weeks' gestation who is diagnosed with intraventricular hemorrhage (IVH)?
- A. Increased muscle tone.
- B. Hyperbilirubinemia.
- C. Bulging fontanels.
- D. Hyperactivity.
Correct Answer: C
Rationale: Bulging fontanels are a sign of increased intracranial pressure from IVH in preterm neonates.
While assessing the fundus of a multiparous client 36 hours after delivery of a term neonate, the nurse notes a separation of the abdominal muscles. The nurse should tell the client:
- A. She will have a surgical repair at 6 weeks postpartum.
- B. To remain on bed rest until resolution occurs.
- C. The separation will resolve on its own with the right posture and diet.
- D. To perform exercises involving head and shoulder raising in a lying position.
Correct Answer: D
Rationale: Diastasis recti often resolves with specific exercises like head and shoulder raises, which strengthen abdominal muscles.
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.