Nokea
The cervix of a primigravid client in active labor who received epidural anesthesia 4 hours ago is now completely dilated, and the client is ready to begin pushing. Before the client begins to push, the nurse should assess:
- A. Fetal heart rate variability.
- B. Cervical dilation again.
- C. Status of membranes.
- D. Bladder status.
Correct Answer: D
Rationale: A full bladder can impede fetal descent and increase discomfort during pushing. Assessing bladder status (and catheterizing if needed) is critical before pushing begins. Fetal heart rate, dilation, and membrane status should already be monitored but are not the priority at this moment.
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When developing the plan of care for a multiparous client in active labor who receives an epidural anesthetic, which of the following would the nurse anticipate that the physician will order if the client develops moderate hypotension?
- A. Ephedrine sulfate.
- B. Epinephrine (Adrenalin Chloride).
- C. Methylergonovine (Methergine).
- D. Atropine sulfate.
Correct Answer: A
Rationale: Ephedrine sulfate is commonly used to treat epidural-related hypotension by increasing blood pressure through vasoconstriction and cardiac stimulation. Epinephrine is for emergencies, methylergonovine treats uterine atony, and atropine addresses bradycardia.
A newborn who is 20 hours old has a respiratory rate of 66 , is grunting when exhaling, and has occasional nasal flaring. The newborn's temperature is 98 ; he is breathing room air and is pink with acrocyanosis. The mother had membranes that were ruptured 26 hours before delivery. Based on these data, the nurse should include which of the following in the management of the infant's care?
- A. Continue recording vital signs, voiding, stooling, and eating patterns every 4 hours for 24 hours.
- B. With a health care provider (HCP) order, draw blood cultures, monitor vital signs every 2 hours as well as feeding and elimination patterns every 4 hours, newborn at bedside.
- C. Transfer the newborn to the neonatal intensive care unit with diagnosis of possible sepsis, parents at bedside.
- D. Request CBC with differential from the health care provider, keep the newborn under the radiant warmer, and monitor vital signs every 4 hours, parents at bedside.
Correct Answer: B
Rationale: The concern with this infant is sepsis based on prolonged rupture of membranes before delivery. Blood cultures would provide an accurate diagnosis of sepsis, but will take 48 hours from the time drawn. Frequent monitoring of infant vital signs, looking for changes, and maintaining contact with the parents is also part of care management while awaiting culture results.
A primigravid client at 39 weeks' gestation is admitted to the hospital for induction of labor. The physician has ordered prostaglandin E2 gel (Dinoprostone) for the client. Before administering prostaglandin E2 gel to the client, which of the following should the nurse do first?
- A. Assess the frequency of uterine contractions.
- B. Place the client in a side-lying position.
- C. Determine whether the membranes have ruptured.
- D. Prepare the client for an amniotomy.
Correct Answer: A
Rationale: Prostaglandin E2 gel stimulates contractions, so assessing baseline contraction frequency ensures it is safe to administer (e.g., no hyperstimulation). Membrane status and positioning are secondary, and amniotomy is not required.
After explaining to a primiparous client about the causes of her neonate's cranial molding, which of the following statements by the mother indicates the need for further instruction?
- A. The molding was caused by an overlapping of the baby's cranial bones during my labor.'
- B. The amount of molding is related to the amount and length of pressure on the head.'
- C. The molding will usually disappear in a couple of days.'
- D. Brain damage may occur if the molding doesn't resolve quickly.'
Correct Answer: D
Rationale: Cranial molding is a normal process that resolves within days and does not cause brain damage, indicating the mother needs further instruction.
The nurse is teaching a multiparous breast-feeding client about managing mastitis. Which instruction is most appropriate?
- A. Stop breast-feeding until symptoms resolve.
- B. Apply warm compresses before feeding.
- C. Take antibiotics only if fever persists.
- D. Massage the breast vigorously during feeding.
Correct Answer: B
Rationale: Warm compresses before feeding promote milk flow and relieve duct blockage, aiding mastitis resolution.