Nokea
Assessment reveals that the fetus of a multigravid client is at +1 station and 8 cm dilated. Based on these data, the nurse should first:
- A. Ask anesthesia to increase epidural rate.
- B. Assist the client to push if she feels the need to do so.
- C. Encourage the client to breathe through the urge to push.
- D. Support family members in providing comfort measures.
Correct Answer: C
Rationale: At 8 cm dilation and +1 station, the client is in the transition phase but not fully dilated (10 cm). Pushing before full dilation can lead to cervical edema or lacerations. Encouraging the client to breathe through the urge to push helps prevent premature pushing while supporting labor progression. Increasing the epidural rate or assisting with pushing is inappropriate at this stage, and while family support is valuable, it is not the priority.
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A preterm neonate admitted to the neonatal intensive care unit at about 30 weeks' gestation is placed in an oxygenated isolette. The neonate's mother tells the nurse that she was planning to breast-feed the neonate. Which of the following instructions about breast-feeding would be most appropriate?
- A. Breast-feeding is not recommended because the neonate needs increased fat in the diet.
- B. Once the neonate no longer needs oxygen and continuous monitoring, breast-feeding can be done.
- C. Breast-feeding is contraindicated because the neonate is preterm.
- D. Gavage feedings using breast milk can be given until the neonate can coordinate sucking and swallowing.
Correct Answer: D
Rationale: Gavage feedings with breast milk allow the neonate to receive the benefits of breast milk while accommodating their immature sucking and swallowing reflexes.
The nurse explains the complications of pregnancy that occur with diabetes to a primigravid client at 10 weeks' gestation who has a 5-year history of insulin-dependent diabetes. Which of the following, if stated by the client as a complication, indicates the need for additional teaching?
- A. Candida albicans infection.
- B. Twin-to-twin transfer.
- C. Polyhydramnios.
- D. Preeclampsia.
Correct Answer: B
Rationale: Twin-to-twin transfer is not a complication of diabetes.
A 24-year-old primigravid client in active labor requests use of the jet hydrotherapy tub to aid in pain relief. The nurse bases the response on the understanding that this therapy is commonly contraindicated for clients with which of the following?
- A. A required membranes.
- B. Multifetal gestation.
- C. Diabetes mellitus.
- D. Hypotonic labor patterns.
Correct Answer: A
Rationale: Jet hydrotherapy (e.g., whirlpool tubs) is contraindicated with ruptured membranes due to the risk of infection from water entering the vaginal canal. Multifetal gestation, diabetes, and hypotonic labor are not absolute contraindications unless other complications are present.
While caring for a primipara diagnosed with deep vein thrombosis at 48 hours postpartum who is receiving treatment with bed rest and intravenous heparin therapy, the nurse should contact the client's physician immediately if the client exhibited which of the following?
- A. Pain in her calf.
- B. Dyspnea.
- C. Hypertension.
- D. Bradycardia.
Correct Answer: B
Rationale: Dyspnea may indicate a pulmonary embolism, a life-threatening complication requiring immediate attention.
The nurse has received shift report on a group of newborns. The nurse should make rounds on which of the following clients first?
- A. A newborn who is large for gestational age (LGA) who needs a repeat blood glucose prior to the next feeding in 15 minutes.
- B. A newborn delivered at 36-weeks' gestation weighing $5 \mathrm{lb}$ who is due to breast-feed for the first time in 15 minutes.
- C. A newborn who was delivered 24 hours ago by Cesarean section and had a respiratory rate of 62 30 minutes ago.
- D. A newborn who had a borderline low temperature and was double-wrapped with a hat on ½ hour ago to bring up the temperature.
Correct Answer: C
Rationale: A respiratory rate of 62 is elevated and may indicate respiratory distress, requiring immediate assessment.