Nokea
The laboring client is requesting IV pain medication instead of epidural anesthesia. The nurse determines that which factor would most definitely contraindicate the administration of nalbuphine hydrochloride?
- A. Completely dilated and 100 percent effaced
- B. Fetal heart rate (FHR) of 120 beats per minute
- C. Reassuring FHR variability and accelerations
- D. Variable decelerations with reassuring FHR
Correct Answer: A
Rationale: Systemic medications, such as nalbuphine hydrochloride (Nubain), should not be administered when advanced dilation is present (transition stage of labor) because its use can lead to respiratory depression if given too close to the time of delivery. An FHR of 120 bpm is within normal parameters of 120 to 160 bpm. Reassuring FHR variability and accelerations are interpreted as adequate placental oxygenation and do not contraindicate administration of nalbuphine hydrochloride. If mild variable decelerations are present but the FHR pattern remains reassuring, nalbuphine hydrochloride can still be administered.
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The nurse is caring for the client admitted to the antepartum unit at 32 weeks’ gestation with possible preterm labor. The nurse is performing a fetal fibronectin (fFN) test. Which event, if it occurred, would require the nurse to recollect the specimen?
- A. The specimen is collected before a vaginal examination.
- B. A lubricant was used to facilitate insertion of the swab.
- C. The client reports that she has not had intercourse for 3 days.
- D. The specimen is collected before other specimens are collected.
Correct Answer: B
Rationale: When collecting a fetal fibronectin test swab, the nurse must not use lubricant, as it will interfere with the collection of the specimen and contaminate the specimen. If this occurs, the test will need to be repeated. The specimen needs to be collected before a vaginal examination in order to ensure that the fluids are not contaminated. The client must not have had sexual intercourse within 24 hours of the specimen collection, as semen will contaminate the specimen. The specimen must be collected before other specimens are collected to maintain the integrity of the specimen.
The nurse caring for the postpartum client who is 15 years old is concerned about this client’s ability to parent a newborn. Which behavior is characteristic of the developmental level of the 15-year-old that justifies the nurse’s concern?
- A. Developing autonomy
- B. Follows rules established by others
- C. Career oriented
- D. Egocentric
Correct Answer: D
Rationale: The development of autonomy is a developmental task of toddlerhood. School-age children are motivated to follow rules established by others. Adult women are concerned about the effect of childbearing on careers. Although it is biologically possible for the adolescent female to become a parent, her egocentricity and concrete thinking interfere with her ability to parent effectively. Because of this normal development, the adolescent may inadvertently neglect her child.
The nurse advises the client to perform which exercise to strengthen pelvic floor muscles?
- A. Kegel exercises
- B. High-impact aerobics
- C. Sit-ups
- D. Weightlifting
Correct Answer: A
Rationale: Kegel exercises strengthen pelvic floor muscles, aiding postpartum recovery and preventing incontinence.
The oncoming shift nurse assesses the fundus of the postpartum client 6 hours after a vaginal birth and finds that it is firm. When the nurse then assists the client out of bed for the first time, blood begins to run down the client’s leg. Which action by the nurse in response to the client’s bleeding is correct?
- A. Explain that extra bleeding can occur with initial standing
- B. Immediately assist the client back into bed
- C. Push the emergency call light in the room
- D. Call the HCP to report this increased bleeding
Correct Answer: A
Rationale: Lochia normally pools in the vagina when the postpartum client remains in a recumbent position for any length of time. When the client then stands, gravity causes the blood to flow out. As long as the nurse knows the fundus is firm and not bleeding, a simple explanation to the client is all that is required. There is no reason to return the client to bed; the fundus is firm. There is no reason to push the emergency call light. Increased bleeding is an expected response when standing for the first time. There is no reason to call the HCP.
When the client asks the nurse about the viability of the ovum after ovulation, the nurse correctly explains that after ovulation, the ovum remains alive for how many hours?
- A. 2 hours
- B. 24 hours
- C. 48 hours
- D. 72 hours
Correct Answer: B
Rationale: The ovum remains viable for approximately 24 hours after ovulation, during which it can be fertilized by sperm.