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A nurse is admitting a client to the labor and delivery unit when the client states, 'My water just broke.' Which of the following interventions is the nurse's priority?
- A. Perform Nitrazine testing.
- B. Assess the fluid.
- C. Check cervical dilation.
- D. Begin FHR monitoring.
Correct Answer: D
Rationale: The correct answer is D: Begin FHR monitoring. This is the priority because the client's water breaking indicates a potential risk to the fetus, such as umbilical cord compression or prolapse. FHR monitoring helps assess fetal well-being and detect any signs of distress. Performing Nitrazine testing (A) and checking cervical dilation (C) can wait until after ensuring fetal safety. Assessing the fluid (B) may provide some information but does not directly address the immediate concern for fetal well-being.
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Which of the following findings should the nurse report to the provider? Select all that apply.
- A. Respiratory findings
- B. Oxygen saturation
- C. Central nervous system findings
- D. Gastrointestinal findings
Correct Answer: C,D
Rationale: The nurse should report central nervous system (CNS) and gastrointestinal (GI) findings to the provider because changes in these systems can indicate serious health issues. CNS findings may suggest neurological problems, while GI findings could indicate digestive issues or potential complications. Reporting these findings promptly allows the provider to assess the patient's condition thoroughly and intervene if necessary. Respiratory and oxygen saturation findings are important but may not always require immediate intervention. Other choices are not directly related to critical health concerns that need urgent attention.
A nurse is caring for a client who is in labor and reports increasing rectal pressure. They are experiencing contractions 2 to 3 min apart, each lasting 80 to 90 seconds, and a vaginal examination reveals that their cervix is dilated to 9 cm. The nurse should identify that the client is in which of the following phases of labor?
- A. Passive descent
- B. Active
- C. Early
- D. Descent
Correct Answer: B
Rationale: The correct answer is B: Active phase. At 9cm dilation, the client is transitioning from the latent phase to the active phase of the first stage of labor. In the active phase, contractions are stronger and more frequent, leading to increased rectal pressure and cervical dilation. This phase typically ranges from 6-10cm dilation. Passive descent (A) refers to the early phase of labor when the cervix is dilating but contractions are mild. Early phase (C) is characterized by 0-3cm dilation. Descent (D) is not a recognized phase of labor. The client's symptoms align with the characteristics of the active phase, making option B the correct choice.
A nurse is assessing a newborn who has neonatal abstinence syndrome. Which of the following findings should the nurse expect?
- A. Diminished deep tendon reflexes
- B. Excessive crying
- C. Decreased muscle tone
- D. Absent Moro reflex
Correct Answer: B
Rationale: The correct answer is B: Excessive crying. Neonatal abstinence syndrome is characterized by withdrawal symptoms in newborns due to exposure to drugs in utero. Excessive crying is a common manifestation of this syndrome as the newborn experiences discomfort and agitation. Diminished deep tendon reflexes (A), decreased muscle tone (C), and absent Moro reflex (D) are not typically associated with neonatal abstinence syndrome. These findings may be seen in other conditions, but not specifically in newborns with this syndrome.
A nurse is providing teaching to a client who is 2 days postpartum and wants to continue using her diaphragm for contraception. Which of the following instructions should the nurse include?
- A. You should have your provider refit you for a new diaphragm.'
- B. You should use an oil-based vaginal lubricant when inserting your diaphragm.'
- C. You should keep the diaphragm in place for at least 4 hours after intercourse.'
- D. You should store your diaphragm in sterile water after each use.'
Correct Answer: A
Rationale: The correct answer is A: "You should have your provider refit you for a new diaphragm." This is important because postpartum changes in the body can affect the fit of the diaphragm. A refitting ensures proper size and fit for effective contraception. Choice B is incorrect because oil-based lubricants can damage latex diaphragms. Choice C is incorrect as the diaphragm should be kept in place for at least 6-8 hours, not 4 hours, for effective contraception. Choice D is incorrect as diaphragms should be stored dry, not in sterile water, to prevent damage.
A nurse is caring for a client who is at 22 weeks of gestation and is HIV positive. Which of the following actions should the nurse take?
- A. Administer penicillin G 2.4 million units IM to the client.
- B. Instruct the client to schedule an annual pelvic examination.
- C. Tell the client they will start medication for HIV immediately after delivery.
- D. Report the client's condition to the local health department.
Correct Answer: C
Rationale: Correct Answer: C. Tell the client they will start medication for HIV immediately after delivery.
Rationale: Starting HIV medication immediately after delivery is crucial in preventing mother-to-child transmission of HIV. Antiretroviral therapy should be initiated during pregnancy to reduce the viral load and continued postpartum to protect the baby. This approach has been shown to significantly reduce the risk of transmission.
Summary of other choices:
A: Administering penicillin G is not directly related to managing HIV in pregnancy.
B: Annual pelvic examinations are important for overall health but not specific to managing HIV in pregnancy.
D: Reporting the client's condition to the health department may be necessary but does not address the immediate need for HIV medication.
E, F, G: No additional choices provided.