Nokea
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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The nurse is assessing fetal presentation in a multiparous client. The illustration below indicates which of the following types of presentation?
- A. Frank breech.
- B. Complete breech.
- C. Footling breech.
- D. Vertex.
Correct Answer: D
Rationale: Without the illustration, the context suggests a typical presentation for a multiparous client, which is most likely vertex (head-down), the most common and favorable for vaginal delivery.
Which of the following instructions about activities during menstruation would the nurse include when counseling an adolescent who has just begun to menstruate?
- A. Take a mild analgesic if needed for menstrual pain.
- B. Avoid cold foods if menstrual pain persists.
- C. Stop exercise while menstruating.
- D. Avoid sexual intercourse while menstruating.
Correct Answer: A
Rationale: Mild analgesics like ibuprofen can effectively manage menstrual pain. There is no evidence supporting avoiding cold foods, and moderate exercise can alleviate cramps. Sexual intercourse during menstruation is a personal choice and not medically contraindicated.
A neonate born at 38 weeks' gestation is admitted to the neonatal nursery for observation. The neonate's mother, who is positive for human immunodeficiency virus (HIV) infection, has received no prenatal care. The mother asks the nurse if her neonate is positive for HIV. The nurse can tell the mother which of the following?
- A. More than $50 \%$ of neonates born to mothers who are positive for HIV will be positive at 18 months of age.'
- B. An enlarged liver at birth generally means the neonate is HIV positive.'
- C. A complete blood count analysis is the primary method for determining whether the neonate is HIV positive.'
- D. Most neonates are asymptomatic at birth and usually test positive for the HIV antibody at this time.'
Correct Answer: D
Rationale: Most neonates born to HIV-positive mothers test positive for HIV antibodies at birth due to maternal antibody transfer but are asymptomatic, with true infection status determined later.
A primigravid client at 37 weeks' gestation has been hospitalized for several days with severe pregnancy-induced hypertension. While caring for the client, the nurse observes that the client is beginning to have a seizure. Which of the following actions should the nurse do first?
- A. Pad the side rails of the client's bed.
- B. Turn the client to the right side.
- C. Insert a padded tongue blade into the client's mouth.
- D. Call for immediate assistance in the client's room.
Correct Answer: D
Rationale: A seizure in pregnancy-induced hypertension (eclampsia) is a medical emergency. Calling for immediate assistance ensures rapid intervention (e.g., magnesium sulfate). Padding rails, repositioning, or inserting a tongue blade (which is outdated) are secondary.
After instruction of a primigravid client at 8 weeks' gestation diagnosed with class I heart disease about self-care during pregnancy, which of the following client statements would indicate the need for additional teaching?
- A. "I should avoid being near people who have a cold."
- B. "I may be given antibiotics during my pregnancy."
- C. "I should reduce my intake of protein in my diet."
- D. "I should limit my salt intake at meals."
Correct Answer: C
Rationale: Reducing protein intake is not recommended for clients with heart disease.