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A primigravida is admitted to the labor area with ruptured membranes and contractions occurring every 2 to 3 minutes, lasting 45 seconds. After 3 hours of labor, the client's contractions are now every 7 to 10 minutes, lasting 30 seconds. The nurse administers oxytocin (Pitocin) as ordered. The expected outcome of this drug is:
- A. The cervix will begin to dilate 2 centimeters per hour.
- B. Contractions will occur every 2 to 3 minutes, lasting 40 to 60 seconds, moderate intensity, resting tone between contractions.
- C. The cervix will change from firm to soft, efface to 40% to 50%, and move from a posterior to anterior position.
- D. Contractions will be every 2 minutes, lasting 60 to 90 seconds, with intrauterine pressure of 70 mm Hg.
Correct Answer: B
Rationale: Oxytocin is used to augment labor by increasing contraction frequency, duration, and intensity. The expected outcome is regular contractions every 2–3 minutes, lasting 40–60 seconds, with moderate intensity and adequate resting tone, promoting effective labor progression. The other options describe unrealistic or unrelated effects.
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A primigravid client delivered vaginally 2 hours ago with no complications. As the nurse plans care for this postpartum client, which postpartum goal would have the highest priority?
- A. By discharge, the family will bond with the neonate.
- B. The client will demonstrate self-care and infant care by the end of the shift.
- C. The client will state instructions for discharge during the first postpartum day.
- D. By the end of the shift, the client will describe a safe home environment.
Correct Answer: B
Rationale: The highest priority in the immediate postpartum period is ensuring the client can perform self-care and infant care, as this promotes safety and independence, which are critical for recovery and newborn care.
Two hours ago, a multigravid client was admitted in active labor with her cervix dilated at 5 cm and completely effaced and the fetus at 0 station. Currently, the client is experiencing nausea and vomiting, a slight chill with perspiration beads on her lip, and extreme irritability. The nurse should first:
- A. Warm the temperature of the room by a few degrees.
- B. Increase the rate of intravenous fluid administration.
- C. Obtain an order for an intramuscular antiemetic medication.
- D. Assess the client's cervical dilation and station.
Correct Answer: D
Rationale: Nausea, chills, perspiration, and irritability are signs of the transition phase (8–10 cm dilation). Assessing cervical dilation and station confirms progression and guides care. Warming the room, increasing fluids, or administering antiemetics are secondary.
While assisting a primiparous client with her first breast-feeding session, which of the following actions should the nurse instruct the mother to do to stimulate the neonate to open the mouth and grasp the nipple?
- A. Pull down gently on the neonate's chin and insert the nipple.
- B. Squeeze both of the neonate's cheeks simultaneously.
- C. Place the nipple into the neonate's mouth on top of the tongue.
- D. Brush the neonate's lips lightly with the nipple.
Correct Answer: D
Rationale: Brushing the neonate's lips with the nipple stimulates the rooting reflex, encouraging the mouth to open.
At a home visit, the nurse assesses a neonate delivered vaginally at 41 weeks' gestation 5 days ago, noting the following findings: frequent hiccups; loose, watery stool in diaper; red rash on face; and dry, peeling skin; which of these findings warrants further assessment?
- A. Frequent hiccups.
- B. Loose, watery stool in diaper.
- C. Pink papular vesicles on the face.
- D. Dry, peeling skin.
Correct Answer: B
Rationale: Loose, watery stool may indicate diarrhea, which requires further assessment to rule out infection or malabsorption.
A 21-year-old primigravid client at 40 weeks' gestation is admitted to the hospital in active labor. The client's cervix is 8 cm and completely effaced at 0 station. During the transition phase of labor, which of the following is a priority nursing diagnosis?
- A. Impaired urinary elimination related to nothing-by-mouth status.
- B. Risk for injury related to hyperventilation and dizziness.
- C. Ineffective coping related to lack of confidence.
- D. Pain related to increasing frequency and intensity of uterine contractions.
Correct Answer: D
Rationale: During the transition phase (8–10 cm), intense and frequent contractions cause significant pain, making pain management the priority nursing diagnosis. Urinary elimination issues are less urgent, hyperventilation is a secondary concern, and coping issues are not as immediate as pain.