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For the past 8 hours, a 20-year-old primigravid client in active labor with intact membranes has been experiencing regular contractions. The fetal heart rate is 136 bpm with good variability. After determining that the client is still in the latent phase of labor, the nurse should observe the client for:
- A. Exhaustion.
- B. Chills and fever.
- C. Fluid overload.
- D. Meconium-stained fluid.
Correct Answer: A
Rationale: Prolonged latent phase (8 hours) in a primigravid client can lead to maternal exhaustion due to sustained effort and lack of progress, impacting labor stamina. Chills/fever, fluid overload, or meconium-stained fluid are less likely without specific risk factors.
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A primiparous client who delivered 12 hours ago under epidural anesthesia with a midline episiotomy tells the nurse that she is experiencing a great deal of discomfort when she sits in a chair with the baby. Which of the following instructions would be most appropriate?
- A. Ask for some pain medication before you sit down.
- B. Squeeze your buttock muscles together before sitting down.
- C. Keep a relaxed posture before sitting down with the possibility of the nurse.
- D. Ask the physician for some analgesic cream or spray.
Correct Answer: B
Rationale: Squeezing buttock muscles before sitting reduces pressure on the episiotomy site, alleviating discomfort.
After the nurse counsels a primiparous client who is breast-feeding her neonate about diet and nutritional needs during the lactation period, which of the following client statements indicates a need for additional teaching?
- A. I need to increase my intake of vitamin D.
- B. I should drink at least five glasses of fluid daily.
- C. I need to get an extra 500 calories per day.
- D. I need to make sure I have enough calcium in my diet.
Correct Answer: B
Rationale: Breastfeeding mothers need 8-10 glasses of fluid daily to support milk production, so five glasses is insufficient.
A septic preterm neonate's I.V. was removed due to infiltration. While restarting the I.V., the nurse should carefully assess the neonate for:
- A. Fever.
- B. Hypoglycemia.
- C. Tachycardia.
Correct Answer: C
Rationale: Tachycardia can indicate pain, stress, or cardiovascular compromise during I.V. insertion, especially in a septic preterm neonate.
After teaching a primiparous client who used cocaine during pregnancy about possible gastrointestinal signs and symptoms in her neonate, which of the following, if stated by the mother as common, indicates effective teaching?
- A. Hypotonia.
- B. Constipation.
- C. Vomiting.
- D. Abdominal distention.
Correct Answer: C
Rationale: Vomiting is a common gastrointestinal symptom in neonates with cocaine exposure due to neurological irritability.
A multigravid laboring client has an extensive documented history of drug addiction. Her last reported usage was 5 hours ago. She is 2 cm dilated with contractions every 3 minutes of moderate intensity. The physician orders nalbuphine (Nubain) 15 mg slow I.V. push for pain relief followed by an epidural when the client is 4 cm dilated. Within 10 minutes of receiving the nalbuphine, the client states she thinks she is going to have her baby now. Of the following drugs available at the time of the delivery, which should the nurse avoid using with this client in this situation?
- A. 1% lidocaine (Xylocaine).
- B. Naloxone hydrochloride (Narcan).
- C. Local anesthetic.
- D. Pudendal block.
Correct Answer: B
Rationale: In a client with recent opioid use, naloxone (Narcan) could precipitate withdrawal symptoms, which is risky during delivery. Lidocaine, local anesthetics, or pudendal blocks are safe for perineal anesthesia and do not interact with the client's history.