Nokea
A term multigravida, who is receiving oxytocin for labor augmentation is requesting pain medication. Review of the client's record indication that she was medicated 30 minutes ago with butorphanol (Stadol) 2 mg and promethazine (Phenergan) 25 mg IV push. Vaginal examination reveals that the client cervical dilation is 3 cm, 70% effaced, and at a 0 station. What action should the nurse implement?
- A. Discontinue the Pitocin infusion
- B. Medicate the client with an additional 1 mg of Stadol IV push
- C. Notify the healthcare provider
- D. Instruct the client to use deep breathing during contraction
Correct Answer: D
Rationale: Deep breathing techniques (D) can help manage pain without additional medication.
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Which patient would require additional calories and nutrients?
- A. A 36-year-old female gravida 2, para 1, in her first trimester of pregnancy
- B. An 18-year-old female who delivered a 7-lb baby and is bottle feeding
- C. A 23-year-old female who had a cesarean birth and is bottle feeding
- D. A 20-year-old female who had a vaginal birth 5 months ago and is breastfeeding
Correct Answer: D
Rationale: The correct answer is D because breastfeeding requires additional calories and nutrients to support the mother's milk production and maintain her own health. Breastfeeding burns extra calories, so the mother needs to consume more to meet her body's needs. Additionally, breastfeeding mothers need to ensure they are getting enough nutrients like calcium, iron, and protein to support their own health and the production of nutritious breast milk for their baby.
Choice A is incorrect because the patient is in her first trimester of pregnancy, not breastfeeding. Choice B is incorrect because bottle feeding does not require as many additional calories and nutrients as breastfeeding. Choice C is incorrect because although the patient had a cesarean birth, the method of feeding (bottle feeding) does not require as much additional nutrition as breastfeeding.
The nurse states to the newly pregnant patient, 'Tell me how you feel about being pregnant.' Which communication technique is the nurse using with this patient?
- A. Clarifying
- B. Paraphrasing
- C. Reflection
- D. Structuring
Correct Answer: A
Rationale: The nurse is attempting to follow up and check the accuracy of the patient's message, which is clarifying.
A 35-year-old primigravida client with severe preeclampsia is receiving magnesium sulfate via continuous IV infusion. Which assessment data indicates to the nurse that the client is experiencing magnesium sulfate toxicity?
- A. Deep tendon reflexes 2+
- B. Blood pressure 140/90
- C. Respiratory rate 18/minute
- D. Urine output 90 ml/4 hours
Correct Answer: D
Rationale: Urine outputs of less than 100 ml/4 hours (D), absent DTRs, and a respiratory rate of less than 12 breaths/minute are cardinal signs of magnesium sulfate toxicity.
The nurse is caring for a multigravida client in active labor with continuous epidural anesthesia. When the client is 7 cm dilated, her blood pressure drops to 90/50 mm Hg, and the fetal heart rate shows signs of decelerations. What action should the nurse take first?
- A. Place the client in a lateral position.
- B. Administer oxygen via face mask.
- C. Increase the rate of IV fluid infusion.
- D. Notify the healthcare provider.
Correct Answer: A
Rationale: Placing the client in a lateral position can improve venous return and blood pressure, addressing both maternal hypotension and fetal distress.
A newborn infant is receiving immunization prior discharge. Which action should the nurse implement?
- A. Give the first dose of the vaccine for rotavirus if any have diarrhea now.
- B. Obtain signed consent from the mother for administration of hepatitis B vaccine
- C. Prepare the first dose for DTaP
- D. Ask the mother if she wants the infant immunized for
Correct Answer: B
Rationale: Hepatitis B vaccine is routinely given at birth, and consent is required (B).