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Primigravida client in second stage of labor, moaning and screaming, husband requests pain medication
A primigravida client in the second stage of labor has been moaning, screaming, and generally vocal throughout her labor. Her husband is distraught seeing his wife this way and asks the nurse for more pain medication for her. What is the nurse's best response?
- A. Assist the client with breathing and imagery techniques in an attempt to calm her down.
- B. Ask the client to describe the intensity of her pain on a scale of 0 to 10.
- C. Page the obstetrician to evaluate the client's pain, and administer an appropriate increase in her pain medication.
- D. Reassure the first-time father that his wife will be fine, and offer to stay with her while he takes a walk.
Correct Answer: A
Rationale: Assisting with breathing and imagery techniques provides nonpharmacological pain relief and supports the client's coping mechanisms, which is appropriate as vocalizing is a normal way to express pain during labor.
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Newborn 1 hour after birth
The nurse completes the initial assessment of a newborn. Which finding would lead the nurse to suspect that the newborn is experiencing difficulty with oxygenation?
- A. Acrocyanosis.
- B. Respiratory rate of 54 breaths/minute.
- C. Nasal flaring.
- D. Abdominal breathing.
Correct Answer: C
Rationale: Nasal flaring indicates difficulty with oxygenation, as it is a compensatory mechanism to increase airflow in respiratory distress.
Client 2 hours postpartum, vaginal birth, saturated two perineal pads in 30 minutes
A nurse is caring for a client 2 hours after a spontaneous vaginal birth and the client has saturated two perineal pads with blood in a 30-minute period. Which of the following is the priority nursing intervention at this time?
- A. Assist the client on a bedpan to urinate.
- B. Increase the client's fluid intake.
- C. Palpate the client's uterine fundus.
- D. Prepare to administer oxytocic medication.
Correct Answer: C
Rationale: Palpating the uterine fundus assesses for uterine atony, a common cause of postpartum hemorrhage indicated by excessive bleeding.
2-day-old newborn
The nurse explains to the parents of a 2-day-old newborn that decreased life span of neonatal red blood cells has contributed to which complication?
- A. Hyperbilirubinemia.
- B. Respiratory distress syndrome.
- C. Polycythemia.
- D. Transient tachypnea.
Correct Answer: A
Rationale: The increased breakdown of neonatal red blood cells, which have a shorter lifespan, produces bilirubin, leading to hyperbilirubinemia and potential jaundice.
Vacuum extraction birth
While assisting with a vacuum extraction birth, what should the nurse immediately report to the physician?
- A. Maternal pulse rate of 100 bpm.
- B. Maternal blood pressure of 120/70 mm Hg.
- C. Decrease in intensity of uterine contractions.
- D. Persistent fetal bradycardia below 100 bpm.
Correct Answer: D
Rationale: Persistent fetal bradycardia below 100 bpm indicates potential fetal distress, requiring immediate reporting to ensure fetal safety.
Newborn, signs of diaphoresis, jitteriness, lethargy
A nurse is caring for a newborn and observes signs of diaphoresis, jitteriness, and lethargy. Which of the following actions should the nurse take?
- A. Obtain blood glucose by heel stick.
- B. Initiate phototherapy.
- C. Monitor the newborn's blood pressure.
- D. Place the newborn in a radiant warmer.
Correct Answer: A
Rationale: These symptoms suggest hypoglycemia, and obtaining a blood glucose level via heel stick is the priority to confirm and guide treatment.