Nokea
The laboring client in the first stage of labor is talking and laughing with her husband. The nurse should conclude that the client is probably in what phase?
- A. Transition
- B. Active
- C. Active pushing
- D. Latent
Correct Answer: D
Rationale: During the latent phase (1—3 cm), the client is usually happy and talkative. During the transition phase (8—10 cm), the client is usually more restless, irritable, and more likely to lose control. During the active phase (4—7 cm), the client may become more anxious and fatigued and needs to concentrate on breathing techniques to cope with the increasingly stronger contractions. The client who is actively pushing is focusing on how effective she is in the descent of the fetus and concentrating on how she is coping with contractions. She is usually not expressing happiness or laughter, and is not talkative.
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The nurse practitioner informs the new nurse that the laboring client’s monitor is showing prolonged decelerations. Which interpretation by the new nurse is correct?
- A. The monitor pattern is U or V shaped, with a decrease in FHR to less than 70 beats/minute (bpm), lasting more than 60 seconds.
- B. The FHR shows an episodic or periodic acceleration that lasts 2 minutes or more but less than 10 minutes in duration.
- C. There is an FHR decrease of 15 bpm or more below baseline occurring for at least 2 but not more than 10 minutes.
- D. The mother’s heart rate is exhibiting intermittent or transient deviations or changes from the baseline heart rate.
Correct Answer: C
Rationale: A prolonged deceleration occurs when the FHR decreases 15 bpm or more below baseline for at least 2 but not more than 10 minutes. The prolonged deceleration may resolve spontaneously or with the aid of interventions. A U- or V-shaped pattern with abrupt decrease in the FHR to less than 70 bpm, lasting more than 60 seconds, describes variable (not prolonged) deceleration typically associated with cord compression. Any episodic or periodic acceleration of FHR that lasts 2 minutes or more but less than 10 minutes in duration describes prolonged acceleration, not deceleration. The fetal heart monitor is monitoring the FHR and not the mother’s heart rate.
Which client is at highest risk for ectopic pregnancy?
- A. A client with a history of pelvic inflammatory disease
- B. A client with a normal ultrasound
- C. A client with regular menstrual cycles
- D. A client taking prenatal vitamins
Correct Answer: A
Rationale: Pelvic inflammatory disease increases the risk of ectopic pregnancy by causing tubal scarring, which can impede embryo passage.
The nurse is caring for the client who is 28 hours postpartum. Which assessment findings should prompt the nurse to notify the HCP of possible puerperal infection? Select all that apply.
- A. Oral temperature of 102.2°F (39°C)
- B. Telangiectasis on the neck and chest
- C. Mild abdominal tenderness with palpation
- D. Lochial discharge that is foul smelling
- E. White blood cell count of 16,500 cells/mm3
Correct Answer: A,D
Rationale: A temperature of 100.4°F (38°C) or higher after 24 hours postpartum is associated with a puerperal infection. Telangiectasis is red, slightly raised vascular “spiders” that may appear during pregnancy over the neck, thorax, face, or arms and remain or fade during the postpartum period. It is not indicative of an infection. Slight abdominal tenderness with palpation is a normal postpartum finding. Malodorous lochia is a common sign of a puerperal infection. A WBC count of 16,500 is normal for the postpartum client; labor produces a mild pro-inflammatory state.
The nurse observes on the monitor tracing of the client in the transition phase of labor that the baseline FHR is 160 and that there is moderate variability with V-shaped decelerations unrelated to contractions. What should the nurse do first?
- A. Prepare for delivery.
- B. Notify the obstetrician.
- C. Apply oxygen nasally.
- D. Reposition the client.
Correct Answer: D
Rationale: Repositioning the client to her side or to knee-chest should be done first to take the pressure off the umbilical cord. Variable decelerations usually result from cord compression and stretching during fetal descent. The fetus has a normal baseline HR and good variability. There is no indication that immediate delivery is necessary. Other measures could correct the V-shaped (variable) decelerations. Other nursing measures are used to correct the V-shaped (variable) decelerations prior to contacting the obstetrician (or midwife). Repositioning the client should be implemented prior to giving her oxygen.
The clinic nurse reviews the laboratory results illustrated from the postpartum client who is 3 days postdelivery. What should the nurse do in response to these results?
- A. Document the laboratory report findings
- B. Assess the client for increased lochia
- C. Assess the client’s temperature orally
- D. Notify the health care provider immediately
Correct Answer: A
Rationale: The only action required is to document the findings; all values are within expected parameters. Nonpathological leukocytosis often occurs during labor and in the immediate postpartum period because labor produces a mild pro-inflammatory state. WBCs should return to normal by the end of the first postpartum week. Hct and Hgb will begin to decrease on postpartum day 3 or 4 from hemodilution. Assessing the client’s lochia is unnecessary with these results. Assessing the client’s temperature is unnecessary with these results. Notifying the HCP is unnecessary with these results.