Nokea
Induction of labor is planned for 31-year-old primigravida 39 weeks. She has insulin dependent diabetes. Which nursing action is more important?
- A. Begin Pitocin 4h after Cytotec (thin the cervix first)
- B. Administer 100mcg Cytotec q2h(no)
- C. Place vaginal gel and ambulate patient 1h
- D. Prepare to induce labor after administering tap water enema
Correct Answer: A
Rationale: The correct answer is A: Begin Pitocin 4h after Cytotec. This is the most important nursing action because it follows the recommended protocol for inducing labor in a diabetic patient. Cytotec is used to thin the cervix, and waiting 4 hours before starting Pitocin reduces the risk of uterine hyperstimulation, which can be dangerous for the mother and baby. Administering Cytotec every 2 hours (choice B) can increase the risk of hyperstimulation. Placing vaginal gel and ambulating the patient (choice C) may not be appropriate in this case as the patient has diabetes. Preparing to induce labor after administering a tap water enema (choice D) is not a priority compared to ensuring a safe induction process for a diabetic patient.
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The nurse is assessing a postpartum client. Which finding requires immediate intervention?
- A. Fundus firm and midline.
- B. Lochia rubra with large clots.
- C. Mild swelling in the perineal area.
- D. Breast tenderness on day 2 postpartum.
Correct Answer: B
Rationale: The correct answer is B because Lochia rubra with large clots could indicate excessive bleeding, which is a postpartum hemorrhage and requires immediate intervention to prevent further complications. A: Fundus firm and midline is a normal finding. C: Mild swelling in the perineal area is expected after childbirth. D: Breast tenderness on day 2 postpartum is a common finding due to milk production starting.
In what stage does the corpus luteum form?
- A. Luteal phase
- B. Follicular phase
- C. Proliferative phase
- D. Shedding of endometrium phase
Correct Answer: A
Rationale: The corpus luteum forms during the luteal phase of the menstrual cycle. After ovulation, the ruptured follicle transforms into the corpus luteum, which secretes progesterone to prepare the uterus for potential pregnancy. If fertilization doesn't occur, the corpus luteum degenerates, leading to a drop in progesterone levels and the start of menstruation. The other choices, such as the follicular phase (B) where the follicles develop, proliferative phase (C) where the endometrium thickens, and shedding of endometrium phase (D) where menstruation occurs, do not involve the formation of the corpus luteum.
A nurse is caring for a client who is postpartum and received methylergonovine. Which of the following findings indicates that the medication was effective?
- A. Fundus firm to palpation
- B. Increase in blood pressure
- C. Increase in lochia
- D. Report of absent breast pain .
Correct Answer: A
Rationale: Step 1: Methylergonovine is a uterotonic drug used to prevent or treat postpartum hemorrhage by causing uterine contractions.
Step 2: Fundus firmness indicates effective contraction of the uterus, helping to control bleeding.
Step 3: A firm fundus also suggests proper involution of the uterus, a crucial process in postpartum recovery.
Step 4: Increase in blood pressure (B) is not a desired effect of methylergonovine and could indicate adverse reactions.
Step 5: Increase in lochia (C) could suggest excessive bleeding or incomplete uterine contraction.
Step 6: Absence of breast pain (D) is not directly related to the effectiveness of methylergonovine in controlling postpartum bleeding.
What is one difference between the copper IUC and the LNG-IUC?
- A. efficacy
- B. placement in the uterus
- C. presence of a normal period
- D. shape
Correct Answer: B
Rationale: The correct answer is B: placement in the uterus. The copper IUC and LNG-IUC differ in where they are positioned in the uterus. The copper IUC is a T-shaped device placed in the uterus to prevent pregnancy through copper ions, while the LNG-IUC releases hormones and is also placed in the uterus but is a different shape, typically a smaller T or a rounded shape. The placement of the device is crucial for its effectiveness and type of hormone release. Other choices (A) efficacy, (C) presence of a normal period, and (D) shape, do not directly differentiate between the two types of IUCs.
A nurse is planning care for a client who is receiving oxytocin by continuous IV infusion for labor induction. Which of the following interventions should the nurse include in the plan?
- A. Increase the infusion rate every 30 to 60 min.
- B. Maintain the client in a supine position.
- C. Titrate the infusion rate by 4 milliunits/min.
- D. Limit IV intake to 4 L per 24 hr.
Correct Answer: C
Rationale: The correct answer is C: Titrate the infusion rate by 4 milliunits/min. This is the appropriate intervention because oxytocin is a potent uterotonic agent used for labor induction. By titrating the infusion rate by 4 milliunits/min, the nurse can closely monitor and adjust the dose to achieve the desired uterine contractions without causing hyperstimulation. Increasing the infusion rate every 30 to 60 min (A) can lead to rapid and uncontrolled contractions. Maintaining the client in a supine position (B) can decrease blood flow to the placenta. Limiting IV intake to 4 L per 24 hr (D) is not necessary and may lead to dehydration.