Nokea
Assessment of a primigravid client reveals cervical dilation at 8 cm and complete effacement. The client complains of severe back pain during this phase of labor. The nurse explains that the client's severe back pain is most likely caused by the fetal occiput being in a position that is identified as which of the following?
- A. Breech.
- B. Transverse.
- C. Posterior.
- D. Anterior.
Correct Answer: C
Rationale: Severe back pain in labor is commonly associated with a posterior occiput position (e.g., occipitoposterior), where the fetal head presses against the maternal sacrum. Breech, transverse, or anterior positions are less likely to cause intense back pain.
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Two hours ago, a multigravid client was admitted in active labor with her cervix dilated at 5 cm and completely effaced and the fetus at 0 station. Currently, the client is experiencing nausea and vomiting, a slight chill with perspiration beads on her lip, and extreme irritability. The nurse should first:
- A. Warm the temperature of the room by a few degrees.
- B. Increase the rate of intravenous fluid administration.
- C. Obtain an order for an intramuscular antiemetic medication.
- D. Assess the client's cervical dilation and station.
Correct Answer: D
Rationale: Nausea, chills, perspiration, and irritability are signs of the transition phase (8–10 cm dilation). Assessing cervical dilation and station confirms progression and guides care. Warming the room, increasing fluids, or administering antiemetics are secondary.
A multigravid client admitted to the labor area is scheduled for a cesarean delivery under spinal anesthesia. After instructions by the anesthesiologist, the nurse determines that the client has understood the instructions when she says which of the following?
- A. The medication will be administered while I am in a side-lying position.'
- B. The anesthetic may cause a severe headache which is treatable.'
- C. My blood pressure may increase if I lie down too soon after the injection.'
- D. I can expect immediate anesthesia that can be reversed very easily.'
Correct Answer: B
Rationale: Spinal anesthesia carries a risk of post-dural puncture headache, which is treatable (e.g., with a blood patch). The side-lying position is for epidural, not spinal, anesthesia; blood pressure typically decreases; and spinal anesthesia is not easily reversed.
Which of the following instructions should the nurse give to the parents of a neonate diagnosed with hyperbilirubinemia who is receiving phototherapy?
- A. Keep the neonate's eyes completely covered.
- B. Use a regular diaper on the neonate.
- C. Offer feedings every 4 hours.
- D. Check the oral temperature every 8 hours.
Correct Answer: A
Rationale: Keeping the neonate's eyes completely covered protects them from potential retinal damage during phototherapy.
The nurse is instructing a preeclamptic client about monitoring the movements of her fetus to determine fetal well-being. Which statement by the client indicates that she needs further instruction about when to call the health care provider concerning fetal movement?
- A. "If the fetus is becoming less active than before."
- B. "If it takes longer each day for the fetus to move 10 times."
- C. "If the fetus stops moving for 12 hours."
- D. "If the fetus moves more often than 3 times an hour."
Correct Answer: D
Rationale: Increased fetal movement can be a sign of distress, so the client should be instructed to report any significant changes in movement.
While the nurse is caring for a neonate at 32 weeks' gestation in an isolette with continuous oxygen administration, the neonate's mother asks why the neonate's oxygen is humidified. The nurse should tell the mother?
- A. The humidity promotes expansion of the neonate's immature lungs.'
- B. The humidity helps to prevent viral or bacterial pneumonia.'
- C. Oxygen is drying to the mucous membranes unless it is humidified.'
- D. Circulation to the baby's heart is improved with humidified oxygen.'
- E. fetal position for a 32-year-old client
Correct Answer: C
Rationale: Humidified oxygen prevents drying of the mucous membranes, which is critical for maintaining airway health in preterm neonates.