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A woman in her third trimester of pregnancy has been in active labor for the past 8 hours and has dilated 3 cm. The nurse's assessment findings and electronic fetal monitoring (EFM) are consistent with hypotonic dystocia, and the healthcare provider (HCP) prescribes an oxytocin drip. Which data is most important for the nurse to monitor?
- A. Preparation for emergency cesarean birth.
- B. Intensity, interval, and length of contractions.
- C. Checking the perineum for bulging.
- D. Client's hourly blood pressure.
Correct Answer: B
Rationale: Monitoring contraction patterns ensures oxytocin efficacy and prevents hyperstimulation in hypotonic dystocia, critical for labor progression.
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A client in active labor receives a prescription for oxytocin 6 milliunits/minute intravenously (IV). The IV bag contains oxytocin 10 units in lactated Ringer's 1,000 mL. How many mL/hour should the nurse program the infusion pump to deliver? (Enter numerical value only.)
Correct Answer: 36
Rationale: Calculated as: (6 milliunits/min ÷ 10,000 milliunits) × 1,000 mL = 0.6 mL/min; 0.6 mL/min × 60 min/hour = 36 mL/hour.
What instructions should the nurse provide to a new mother regarding postpartum care and monitoring the newborn's health?
- A. You will need to set up an appointment with your obstetrician in 8 weeks.
- B. You will need to abstain from sexual activities untilå½¼æ¤, and until you see your obstetrician.
- C. Contact the pediatrician if the baby is not breastfeeding well or has fewer wet diapers and stools.
- D. The lactation nurse will be coming by to work with you and your baby.
Correct Answer: C
Rationale: Monitoring breastfeeding success and diaper output is critical for detecting newborn health issues like dehydration, unlike incorrect obstetrician visit timing or less comprehensive lactation support.
A 26-week gestational primigravida who is carrying twins is seen in the clinic today. Her fundal height is measured at 29 cm. Based on these findings, which action should the nurse implement?
- A. Document the finding in the medical record.
- B. Schedule the client for a biophysical profile.
- C. Request another nurse measure the fundus.
- D. Notify the healthcare provider of the finding.
Correct Answer: B
Rationale: A fundal height of 29 cm at 26 weeks in a twin pregnancy is discrepant and may indicate issues like growth restriction or polyhydramnios, necessitating a biophysical profile to assess fetal well-being.
The day shift nurse reviews the nurse's notes, labs, and flow sheet from the night before. The nurse plans on providing health teaching for the client and her family in preparation for discharge health teaching. For each teaching point, indicate whether it is Indicated (appropriate or necessary) or Contraindicated (could be harmful). Each box must have one option selected.
- A. You will need to set up an appointment with your pediatrician for 3 weeks from discharge.
- B. The discharge planning nurse will set up home bilirubin lights for you to use until you see the pediatrician.
- C. You will need to set up an appointment with your obstetrician in 8 weeks.
Correct Answer: A,B,C
Rationale: A: Indicated - Pediatric check-ups at 2-4 weeks monitor newborn health. B: Indicated - Bilirubin lights treat jaundice, preventing complications. C: Contraindicated - Obstetrician visits are typically at 6 weeks, not 8.
A client who is positive for Neisseria gonorrhoeae vaginally delivered a newborn. Which medication should the nurse administer to the newborn?
- A. Erythromycin ointment.
- B. Neomycin ointment.
- C. Tetracaine eye drops.
- D. Latanoprost eye drops.
Correct Answer: A
Rationale: Erythromycin ointment prevents ophthalmia neonatorum from Neisseria gonorrhoeae, protecting the newborn's eyes from infection.