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A primipara client at 42 weeks gestation is admitted for induction. Within one hour after initiating an oxytocin infusion, her cervix is 100% effaced and 6 cm dilated, contractions are occurring every 1 minute with a 75-second duration. The nurse stops the oxytocin and starts oxygen. After 30 minutes of uterine rest, the contractions are occurring every 5 minutes with 20-second duration. Which intervention should the nurse implement?
- A. Notify the nursery about the client's response.
- B. Restart oxytocin infusion rate per protocol.
- C. Stop oxygen per cannula.
- D. Check for clonus in both feet.
Correct Answer: B
Rationale: Restarting oxytocin per protocol resumes labor induction safely after uterine rest, ensuring continued progress without hyperstimulation.
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A nurse is conducting a preconception class for a group of parents who are anticipating having children. Which client(s) should the nurse refer for genetic counseling? (Select all that apply)
- A. A couple who express concern about birth defects after using an internet DNA testing site.
- B. A woman and her significant other who are excited about the prospect of having children.
- C. A woman planning to start a second family after the loss of an embryo following an in-vitro fertilization procedure.
- D. A man who states that his father was recently diagnosed with Huntington's disease.
- E. A couple who plan to use in-vitro fertilization with donated sperm.
Correct Answer: A,C,D,E
Rationale: Concerns about birth defects, embryo loss, Huntington's disease, and donor sperm use indicate potential genetic risks requiring counseling, unlike general excitement about having children.
The nurse is reviewing laboratory results and nurse's notes to determine which actions to take at this time. Which actions are appropriate for the nurse to take at this time? (Select all that apply)
- A. Observe for signs of respiratory distress and monitor oxygenation by pulse oximetry.
- B. Keep infant in warmer with bilirubin lights to maintain temperature of 97.6° F (36.4° C).
- C. Monitor temperature.
- D. Continue to monitor glucose levels.
- E. Explain to the mother that the baby's respiratory rate needs to be below 60 breaths/minute to be able to breastfeed.
- F. Tell the mother that she will need to discuss any concerns with the neonatologist.
- G. Inform the mother that the baby is stable enough to take out of the warmer and bilirubin lights.
Correct Answer: A,B,C,D
Rationale: Monitoring respiratory distress, temperature, and glucose levels ensures newborn stability, while bilirubin lights treat jaundice, addressing critical neonatal needs.
Assessment findings of a 4-hour-old newborn include murmur, irregular respiratory rate at 64 breaths/min, heart rate of 150 beats/min with soft murmur, jitteriness, hypotonic, and weak cry. Based on these findings, which action should the nurse implement?
- A. Obtain a heel stick blood glucose level.
- B. Document the findings in the record.
- C. Swaddle the infant in a warm blanket.
- D. Place a pulse oximeter on the heel.
Correct Answer: A
Rationale: Jitteriness, hypotonia, and weak cry suggest hypoglycemia; a heel stick glucose test is critical for confirmation and prompt treatment.
When is the best time to administer a rubella vaccine to a client?
- A. After the client reaches 20-weeks gestation.
- B. Immediately, at 6-weeks gestation, to protect this fetus.
- C. Early postpartum, within 72 hours after delivery.
- D. After the client stops breastfeeding.
Correct Answer: C
Rationale: Administering the rubella vaccine postpartum within 72 hours ensures maternal immunity for future pregnancies without fetal risk, as it's a live vaccine contraindicated in pregnancy.
A client whose labor is being augmented with an oxytocin infusion requests an epidural for pain control. Findings of the last vaginal exam, performed 1 hour ago, were 3 cm cervical dilation, 60% effacement, and a -2 station. Which action should the nurse implement first?
- A. Request placement of the epidural.
- B. Give a bolus of intravenous fluids.
- C. Decrease the oxytocin infusion rate.
- D. Determine current cervical dilation.
Correct Answer: D
Rationale: Assessing current cervical dilation ensures labor progress is suitable for epidural placement, preventing complications like slowed labor.