Nokea
A primigravid client whose cervix is 7 cm dilated with the fetus at 0 station and in a left occipitoposterior (LOP) position requests pain relief for severe back pain. The nurse should:
- A. Provide firm pressure to the client's sacral area.
- B. Prepare the client for a cesarean delivery.
- C. Prepare the client for a precipitate delivery.
- D. Place the client in a left side-lying position.
Correct Answer: A
Rationale: LOP position often causes severe back pain due to the fetal occiput pressing against the sacrum. Firm sacral pressure (counterpressure) can alleviate this pain. Cesarean or precipitate delivery is not indicated unless other complications arise, and side-lying may help but is less specific.
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A multigravid laboring client has an extensive documented history of drug addiction. Her last reported usage was 5 hours ago. She is 2 cm dilated with contractions every 3 minutes of moderate intensity. The physician orders nalbuphine (Nubain) 15 mg slow I.V. push for pain relief followed by an epidural when the client is 4 cm dilated. Within 10 minutes of receiving the nalbuphine, the client states she thinks she is going to have her baby now. Of the following drugs available at the time of the delivery, which should the nurse avoid using with this client in this situation?
- A. 1% lidocaine (Xylocaine).
- B. Naloxone hydrochloride (Narcan).
- C. Local anesthetic.
- D. Pudendal block.
Correct Answer: B
Rationale: In a client with recent opioid use, naloxone (Narcan) could precipitate withdrawal symptoms, which is risky during delivery. Lidocaine, local anesthetics, or pudendal blocks are safe for perineal anesthesia and do not interact with the client's history.
While the nurse is preparing to assist the primiparous client to the bathroom to void 6 hours after a vaginal delivery under epidural anesthesia, the client says that she feels dizzy when sitting up on the side of the bed. The nurse explains that this is most likely caused by which of the following?
- A. Effects of the anesthetic during labor.
- B. Hemorrhage during the delivery process.
- C. Effects of analgesics used during labor.
- D. Decreased blood volume in the vascular system.
Correct Answer: A
Rationale: Dizziness when sitting up is likely due to residual effects of epidural anesthesia, which can cause orthostatic hypotension.
A client asks about the differences between the copper IUD and the hormonal IUD. Which of the following responses by the nurse is accurate?
- A. The copper IUD is hormone-free and may increase menstrual bleeding, while the hormonal IUD may reduce bleeding.
- B. Both IUDs require replacement every year.
- C. The copper IUD prevents ovulation, while the hormonal IUD does not.
- D. The hormonal IUD is less effective than the copper IUD.
Correct Answer: A
Rationale: The copper IUD is hormone-free and may increase menstrual bleeding, while the hormonal IUD releases progestin and may reduce bleeding. Both last several years, neither primarily prevents ovulation, and both are highly effective.
Which of the following observations is expected when the nurse is assessing the gestational age of a neonate delivered at term?
- A. Ear lying flat against the head.
- B. Absence of rugae in the scrotum.
- C. Sole creases covering the entire foot.
- D. Square window sign angle of 90 degrees.
Correct Answer: C
Rationale: Sole creases covering the entire foot are characteristic of a term neonate, indicating full gestational maturity.
Two weeks after a breast-feeding primiparous client is discharged, she calls the birthing center and says that she is afraid she is "losing my breast milk. The baby had been nursing every 4 hours, but now she's crying to be fed every 2 hours." The nurse interprets the neonate's behavior as most likely caused by which of the following?
- A. Lack of adequate intake to meet maternal nutritional needs.
- B. The mother's fears about the baby's weight gain.
- C. Preventing the neonate from sucking long enough with each feeding.
- D. The neonate's temporary growth spurt, which requires more feedings.
Correct Answer: D
Rationale: Increased feeding frequency at 2 weeks is typical of a growth spurt, requiring more frequent nursing.