Nokea
Assessment of a 15-year-old primigravid client at term in active labor reveals cervical dilation at 7 cm with complete effacement. The nurse should assess the client for which of the following first?
- A. Uterine inversion.
- B. Cephalopelvic disproportion (CPD).
- C. Rapid third stage of labor.
- D. Decreased ability to push.
Correct Answer: B
Rationale: At 7 cm dilation in active labor, assessing for cephalopelvic disproportion is critical, as it can impede labor progression and may require intervention. Uterine inversion and rapid third stage occur post-delivery, and decreased pushing ability is relevant only in the second stage.
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A client with pregnancy-induced hypertension is to receive magnesium sulfate to run at 3 grams per hour with normal saline to maintain the total I.V. rate at 125 mL/hour. The nurse giving end of shift report stated the client's blood pressures have been elevated during the night. The oncoming nurse checked the client and found magnesium sulfate running at 2 grams per hour. Identify the nursing actions to be taken from first to last.
- A. Correct the I.V. rates to magnesium sulfate running at 3 grams/hour and normal saline to complete total rate at 125 mL/hour.
- B. Initiate an incident report.
- C. Assess the client's current status.
- D. Notify the physician of the incident.
Correct Answer: C,A,D,B
Rationale: Assess the client first, correct the error, notify the physician, and then document the incident.
The physician orders intermittent fetal heart rate monitoring for a 20-year-old obese primigravid client at 40 weeks' gestation who is admitted to the birthing center in the first stage of labor. The nurse should monitor the client's fetal heart rate pattern at which of the following intervals?
- A. Every 15 minutes during the latent phase.
- B. Every 30 minutes during the active phase.
- C. Every 60 minutes during the initial phase.
- D. Every 2 hours during the transition phase.
Correct Answer: B
Rationale: For a low-risk primigravid client in the active phase of the first stage of labor, intermittent fetal heart rate monitoring is typically performed every 30 minutes to ensure fetal well-being, as per standard obstetric guidelines. More frequent monitoring (every 15 minutes) is reserved for the second stage or high-risk cases, while less frequent intervals (every 60 minutes or 2 hours) are insufficient for active labor.
A client is considering permanent contraception. Which of the following client statements indicates a need for further teaching?
- A. Tubal ligation is considered permanent.
- B. Vasectomy requires a follow-up sperm count.
- C. Tubal ligation will cause early menopause.
- D. Both procedures require general anesthesia.
Correct Answer: C
Rationale: Tubal ligation does not cause early menopause, as it only blocks the fallopian tubes and does not affect ovarian hormone production. The other statements are correct, though anesthesia type may vary.
Soon after admission of a primigravid client at 38 weeks' gestation with severe preeclampsia, the physician orders a continuous intravenous infusion of 5% dextrose in Ringer's solution and 4 g of magnesium sulfate. While the medication is being administered, which of the following assessment findings should the nurse report immediately?
- A. Respiratory rate of 12 breaths/minute.
- B. Patellar reflex of +2.
- C. Blood pressure of 160/88 mm Hg.
- D. Urinary output exceeding intake.
Correct Answer: A
Rationale: A respiratory rate of 12 breaths/minute indicates potential magnesium sulfate toxicity.
The physician who elects to perform a cesarean delivery on a primigravid client for fetal distress has informed the client of possible risks during the procedure. When the nurse asks the client to sign the consent form, the client's husband says, 'I'll sign it for her. She's too upset by what is happening to make this decision.' The nurse should:
- A. Ask the client if this is acceptable to her.
- B. Have the client and her husband both sign the consent form.
- C. Ask the client to sign the consent form.
- D. Ask the doctor to witness the consent form.
Correct Answer: C
Rationale: The client must provide informed consent unless incapacitated. The nurse should ask the client to sign, ensuring she understands despite her distress. The husband cannot sign unless legally authorized, and dual signatures or physician witnessing are unnecessary.