Nokea
A nurse is caring for a client who is in preterm labor at 32 weeks of gestation. The client asks the nurse, "Will my baby be okay?" Which of the following responses should the nurse offer?
- A. "You must be feeling scared and powerless."
- B. "Everyone worries about her baby when she's in labor."
- C. "Your pregnancy is advanced so your baby should be fine."
- D. "We have a neonatal unit here that's equipped to handle emergencies."
Correct Answer: D
Rationale: The most appropriate response for the nurse to offer in this situation is to inform the client that there is a neonatal unit equipped to handle emergencies. This response provides the client with reassurance that if there are any complications with the baby being born prematurely, there is a specialized unit available to provide the necessary care. It addresses the client's concern about the well-being of her baby while also offering a practical solution in case of any emergencies.
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The nurse is reviewing a prenatal client's record and notes a diagnosis of oligohydramnios. What complication is associated with this condition?
- A. Preterm labor.
- B. Fetal growth restriction.
- C. Cord prolapse.
- D. Placenta previa.
Correct Answer: B
Rationale: Oligohydramnios, or low amniotic fluid levels, is often associated with fetal growth restriction.
What is Lamaze International Childbirth Education based on?
- A. breathing techniques
- B. comprehensive evidence-based childbirth teachings
- C. empowerment of the nursing staff
- D. positions to promote breast-feeding
Correct Answer: B
Rationale: Lamaze focuses on evidence-based practices to empower birthing individuals, not just breathing techniques or nursing staff.
The nurse is preparing a client for induction of labor. What is the primary purpose of administering oxytocin?
- A. Enhance cervical dilation.
- B. Increase maternal blood pressure.
- C. Strengthen uterine contractions.
- D. Prevent postpartum hemorrhage.
Correct Answer: C
Rationale: Oxytocin is used to stimulate uterine contractions to induce or augment labor.
A nurse is caring for a client following a vaginal delivery of a term fetal demise. Which of the following statement should the nurse make?
- A. "You can bathe and dress your baby if you'd like to."
- B. "If you don't hold the baby, it will make letting go much harder."
- C. "You should name the baby so she can have an identity."
- D. "I'm sure you will be able to have another baby when you're ready."
Correct Answer: A
Rationale: In this situation, it is important for the nurse to provide the client with options for how they would like to proceed. By offering the option to bathe and dress the baby, the nurse is allowing the client to make decisions about their care and how they would like to cope with the loss. This empowers the client and respects their individual grieving process. It is crucial to encourage the client to make choices that align with their feelings and provide them with support and sensitivity during this difficult time.
A nurse is caring for a client who is in active labor with 7 cm of cervical dilation and 100% effacement. The fetus is at 1+ station, and the client's amniotic membranes are intact. The client suddenly states that she needs to push. Which of the following actions should the nurse
- A. Assist the client into a comfortable position.
- B. Observe the perineum for signs of crowning.
- C. Have the client pant during the next contractions.
- D. Help the client to the bathroom to void.
Correct Answer: B
Rationale: The sudden urge to push along with the advanced cervical dilation, effacement, and station indicates that the client is likely in the second stage of labor, which is the stage of active pushing. When a woman feels the urge to push, it is essential to assess for the crowning of the fetal head at the perineum as this indicates that the baby is descending and will soon be born. This assessment helps the nurse determine the appropriate actions to take next in assisting the delivery process. Waiting for signs of crowning before guiding the client to push can prevent potential complications related to a rapid birth and help facilitate a more controlled delivery process.