Nokea
The health care provider has performed an amniotomy on a laboring client. Which of the following details must be included in the documentation of this procedure? Select all that apply.
- A. Time of rupture.
- B. Color and clarity of fluid.
- C. Fetal heart rate (FHR) and pattern before and after the procedure.
- D. Size of amnio-hook used during the procedure.
- E. Odor and amount of fluid.
Correct Answer: A,B,C,E
Rationale: Documentation of an amniotomy includes the time, fluid characteristics (color, clarity, odor, amount), and fetal heart rate before and after to assess fetal response. The size of the amnio-hook is not clinically relevant.
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A nurse is discussing emergency contraception with a client. Which of the following statements by the nurse is accurate?
- A. Emergency contraception is most effective when taken within 72 hours of unprotected intercourse.
- B. Emergency contraception requires a prescription for all women.
- C. Emergency contraception is 100% effective in preventing pregnancy.
- D. Emergency contraception can be used as a regular method of birth control.
Correct Answer: A
Rationale: Emergency contraception, like Plan B, is most effective within 72 hours of unprotected intercourse. It is available over-the-counter for those 17 and older, is not 100% effective, and is not suitable for regular use due to lower efficacy and side effects.
A multigravid client admitted to the labor area is scheduled for a cesarean delivery under spinal anesthesia. After instructions by the anesthesiologist, the nurse determines that the client has understood the instructions when she says which of the following?
- A. The medication will be administered while I am in a side-lying position.'
- B. The anesthetic may cause a severe headache which is treatable.'
- C. My blood pressure may increase if I lie down too soon after the injection.'
- D. I can expect immediate anesthesia that can be reversed very easily.'
Correct Answer: B
Rationale: Spinal anesthesia carries a risk of post-dural puncture headache, which is treatable (e.g., with a blood patch). The side-lying position is for epidural, not spinal, anesthesia; blood pressure typically decreases; and spinal anesthesia is not easily reversed.
A nurse is reviewing a client's maternal prenatal record and notes that the mother used narcotics during her pregnancy. A primary nursing intervention when caring for a drug-exposed neonate is to:
- A. Assess vital signs including blood pressure every hour.
- B. Minimize environmental stimuli.
- C. Place the infant in a well-lighted area for observation.
- D. Provide stimulation to increase adaptation to the environment.
Correct Answer: B
Rationale: Minimizing environmental stimuli reduces stress and overstimulation in drug-exposed neonates, who are often hypersensitive.
The physician has ordered prostaglandin gel to be administered vaginally to a newly admitted primigravid client. Which of the following indicate that the client has had a therapeutic response to the medication?
- A. Resting period of 2 minutes between contractions.
- B. Normal patellar and elbow reflexes for the past 2 hours.
- C. Softening of the cervix and beginning effacement.
- D. Leaking of clear amniotic fluid in small amounts.
Correct Answer: C
Rationale: Prostaglandin gel is used for cervical ripening. A therapeutic response is indicated by cervical softening and effacement, preparing the cervix for labor. Resting periods and reflexes are unrelated to the gel's purpose, and leaking amniotic fluid suggests rupture of membranes, not a direct effect of the gel.
A laboring client with preeclampsia is prescribed magnesium sulfate 2 g/hour I.V. piggyback. The pharmacy sends the I.V. to the unit labeled magnesium sulfate 20 g/500 mL normal saline. To deliver the correct dose, the nurse should set the pump to deliver how many milliliters per hour?
Correct Answer: 50
Rationale: To calculate the correct dose: (2 g/hour * 500 mL) / 20 g = 50 mL/hour.