Nokea
Several pregnant clients are waiting to be seen in the triage area of the obstetrical unit. Which client should the nurse see first?
- A. A client at 13 weeks' gestation experiencing nausea and vomiting three times a day with +1 ketones in her urine.
- B. A client at 37 weeks' gestation who is an insulin-dependent diabetic and experiencing 3 to 4 fetal movements per day.
- C. A client at 32 weeks' gestation who has preeclampsia and +3 proteinuria who is returning for evaluation of epigastric pain.
- D. A primigravida at 17 weeks' gestation complaining of not feeling fetal movement at this point in her pregnancy.
Correct Answer: C
Rationale: Epigastric pain in a preeclamptic client can indicate impending eclampsia.
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A neonate is admitted to the neonatal intensive care unit for observation with a diagnosis of probable meconium aspiration syndrome (MAS). The neonate weighs10 lb, 4 oz (4,650 g) and is at 41 weeks' gestation. Which of the following nursing diagnoses would be the priority for this neonate?
- A. Impaired skin integrity related to post-term status.
- B. Imbalanced nutrition: More than body requirements related to large size.
- C. Risk for impaired parent-infant-child attachment related to transfer to the intensive care unit.
- D. Impaired gas exchange related to the effects of respiratory distress.
Correct Answer: D
Rationale: Impaired gas exchange is the priority due to the respiratory distress associated with meconium aspiration syndrome.
Before placing the fetal monitoring device on a primigravid client's fundus, the nurse performs Leopold's maneuvers. When performing the third maneuver, the nurse explains that this maneuver is done for which of the following reasons?
- A. To determine whether the fetal presenting part is engaged.
- B. To locate the fetal cephalic prominence.
- C. To distinguish between a breech and a cephalic presentation.
- D. To locate the position of the fetal arms and legs.
Correct Answer: A
Rationale: The third Leopold's maneuver assesses the presenting part's engagement in the pelvis, helping determine labor progression. Other maneuvers address cephalic prominence, presentation type, or fetal positioning.
A full-term client is admitted for an induction of labor. The health care provider has assigned a Bishop score of 10. Which drug would the nurse anticipate administering to this client?
- A. Oxytocin (Pitocin) 10 units in 500 mL D5W.
- B. Prostaglandin gel (Prepidil) 0.5 mg.
- C. Misoprostol (Cytotec) 50 mcg P.O.
- D. Dinoprostone (Cervidil) 10 mg.
Correct Answer: A
Rationale: A Bishop score of 10 indicates a favorable cervix for induction, so oxytocin (Pitocin) is appropriate to initiate contractions. Prostaglandins (Prepidil, Cervidil, Cytotec) are used for cervical ripening when the cervix is unfavorable.
A nurse is teaching a client about the lactational amenorrhea method. Which of the following instructions should the nurse include?
- A. Exclusively breastfeed and remain amenorrheic for up to 6 months postpartum.
- B. Breastfeed at least once daily for up to 12 months.
- C. Use this method if your periods have returned.
- D. Supplement with formula for flexibility.
Correct Answer: A
Rationale: The lactational amenorrhea method requires exclusive breastfeeding, amenorrhea, and being less than 6 months postpartum to suppress ovulation effectively. The other options reduce its reliability.
While a client is being admitted to the birthing unit she states, 'My water broke last night, but my labor started two hours ago.' Which of the following is a concern? Select all that apply.
- A. Maternal lacerations.
- B. 130/80 mm Hg.
- C. Blood and mucus on perineal pad.
- D. Baseline fetal heart rate of 140 with a range between 110 and 160 with contractions.
- E. Peripad stained with green fluid.
- F. The client states, 'This baby wants out-he keeps kicking me.'
Correct Answer: E
Rationale: Prolonged rupture of membranes (>18 hours) increases infection risk, and green fluid suggests meconium, indicating potential fetal distress. Normal blood pressure, bloody show, fetal heart rate variability, and fetal movement are not immediate concerns.