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The client on the labor unit has been experiencing frequent, painful contractions for the last 6 hours. The contractions are of poor quality, and there has been no cervical change. Which interventions should the nurse implement? Select all that apply.
- A. Maintain bed rest
- B. Administer a sedative
- C. Administer an analgesic
- D. Prepare for cesarean delivery
- E. Prepare to start oxytocin
Correct Answer: A,B,C,E
Rationale: This client is experiencing a hypertonic labor pattern in which her contractions are frequent and painful, but no cervical change has occurred. This client should be encouraged to rest often. A sedative should be given to assist the client to rest. Because the contractions are painful, an analgesic should be administered to help the client relax and cope more effectively. If the hypertonic labor pattern continues, augmentation should be initiated with either an oxytocin infusion or amniotomy. A cesarean birth is not a treatment for a hypertonic labor pattern unless a nonreassuring FHR pattern is present.
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When planning for this test, which one of the following items should the nurse have available?
- A. The emergency crash cart
- B. A cardiac monitor
- C. An ultrasound machine
- D. A fetal monitor
Correct Answer: D
Rationale: A nonstress test requires a fetal monitor to assess fetal heart rate and movement, ensuring fetal well-being.
Which expected outcome should the nurse include based on the client's eating habits?
- A. The client will eat three balanced meals and two snacks daily while pregnant.
- B. The client will gain a total of 50 pounds during the pregnancy.
- C. The client will take two prenatal vitamins daily.
- D. The client will report eating about 2,000 calories per day.
Correct Answer: A
Rationale: Eating three balanced meals and two snacks daily addresses the client's poor eating habits and supports nutritional needs.
Which item should the client include in her hospital bag?
- A. Comfortable loose clothing
- B. High-heeled shoes
- C. Heavy perfumes
- D. Large meals
Correct Answer: A
Rationale: Comfortable loose clothing is practical for labor and postpartum, ensuring ease and comfort.
Which statement by the client indicates a need for additional teaching regarding chlamydial infection?
- A. My sex partner(s) will require treatment as well.
- B. I will have to have a cesarean birth to protect my baby.
- C. The physician will treat the infection with an antibiotic.
- D. My Pap smear results may show abnormal cells.
Correct Answer: B
Rationale: Chlamydia does not typically require a cesarean birth; antibiotics treat the infection, and partners need treatment to prevent reinfection.
The nurse assesses the fundal height for multiple pregnant clients. For which client should the nurse conclude that a fundal height measurement is most accurate?
- A. The pregnant client with uterine fibroids
- B. The pregnant client who is obese
- C. The pregnant client with polyhydramnios
- D. The pregnant client experiencing fetal movement
Correct Answer: D
Rationale: Excessive fetal movement may make it difficult to measure the client’s fundal height; however, it should not cause an inaccuracy in the measurement. Fibroids can increase fundal height and give a false measurement. Obesity can increase fundal height and give a false measurement. Polyhydramnios can increase fundal height and give a false measurement.