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The labor and delivery nurse is assigned to triage for the day. There are four clients already in rooms and the following reports have been received about each of these clients. To provide the safest care and best manage time, the nurse should plan to see which client first?
- A. A primipara in active labor at 5 cm asking to be admitted and wanting an epidural.
- B. A primipara who is 100% effaced, 8 cm dilated, and ready to push.
- C. A multipara who thinks her water broke 2 hours ago.
- D. A multipara with contractions every 5 minutes who is 3 cm dilated.
Correct Answer: B
Rationale: A primipara at 8 cm, 100% effaced, and ready to push is in the second stage of labor, requiring immediate attention to prepare for delivery. Other clients are in earlier stages or need assessment but are less urgent.
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A mother is visiting her neonate in the neonatal intensive care unit. Her baby is fussy and the mother wants to know what to do. In order to quiet a sick neonate, which of the following can the nurse teach the mother to do?
- A. Bring in toys for distraction.
- B. Place a musical mobile over the crib.
- C. Stroke the neonate's back.
- D. Use constant, gentle touch.
Correct Answer: D
Rationale: Constant, gentle touch is soothing and minimizes overstimulation for a sick neonate.
A client is considering the fertility awareness method. Which of the following client statements indicates understanding?
- A. I will track my basal body temperature daily.
- B. I can use this method with irregular cycles.
- C. I will monitor ovulation with a pregnancy test.
- D. I will avoid intercourse throughout the cycle.
Correct Answer: A
Rationale: Tracking basal body temperature daily is a key component of the fertility awareness method. It is less reliable with irregular cycles, pregnancy tests do not monitor ovulation, and intercourse is avoided only during fertile periods.
The physician orders docusate sodium (Colace) 100 mg at bedtime for a primiparous client after vaginal delivery of a term neonate after a midline episiotomy. The nurse instructs the client to expect which of the following results from taking the medication?
- A. Relief from episiotomy pain.
- B. Contraction of the uterus.
- C. Softening of the stool.
- D. Aid in sleeping.
Correct Answer: C
Rationale: Docusate sodium is a stool softener, which helps prevent straining during bowel movements, especially important after an episiotomy.
A primigravida is admitted to the labor area with ruptured membranes and contractions occurring every 2 to 3 minutes, lasting 45 seconds. After 3 hours of labor, the client's contractions are now every 7 to 10 minutes, lasting 30 seconds. The nurse administers oxytocin (Pitocin) as ordered. The expected outcome of this drug is:
- A. The cervix will begin to dilate 2 centimeters per hour.
- B. Contractions will occur every 2 to 3 minutes, lasting 40 to 60 seconds, moderate intensity, resting tone between contractions.
- C. The cervix will change from firm to soft, efface to 40% to 50%, and move from a posterior to anterior position.
- D. Contractions will be every 2 minutes, lasting 60 to 90 seconds, with intrauterine pressure of 70 mm Hg.
Correct Answer: B
Rationale: Oxytocin is used to augment labor by increasing contraction frequency, duration, and intensity. The expected outcome is regular contractions every 2–3 minutes, lasting 40–60 seconds, with moderate intensity and adequate resting tone, promoting effective labor progression. The other options describe unrealistic or unrelated effects.
The physician orders intravenous magnesium sulfate for a primigravid client at 38 weeks' gestation diagnosed with severe preeclampsia. Which of the following medications should the nurse have readily available at the client's bedside?
- A. Diazepam(Valium).
- B. Hydralazine(Apresoline).
- C. Calcium gluconate.
- D. Phenytoin(Dilantin).
Correct Answer: C
Rationale: Calcium gluconate is the antidote for magnesium sulfate toxicity.