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 screening prenatal clients who may be carriers for potential genetic abnormalities. Which ethnic group should the nurse identify as having the lowest risk for hemoglobinopathies, such as sickle cell disease and thalassemia?
- A. African descent
- B. Southeast Asian descent
- C. Scandinavian descent
- D. Mediterranean descent
Correct Answer: C
Rationale: Individuals of Scandinavian descent are not an identified risk group for hemoglobinopathies. Individuals of African descent are at risk for hemoglobinopathies and should be offered carrier screening. Individuals of Southeast Asian descent are at risk for hemoglobinopathies and should be offered carrier screening. Individuals of Mediterranean descent are at risk for hemoglobinopathies and should be offered carrier screening.
The nurse correctly explains to the group that the discomfort associated with varicose veins is relieved by which activity?
- A. Resting with the feet in a dependent position
- B. Sitting for periods of time when possible
- C. Putting on calf-length, elastic-top hose
- D. Moving around after standing in one position
Correct Answer: C
Rationale: Elastic-top hose improves venous return, reducing discomfort from varicose veins, unlike dependent positioning or sitting.
The pregnant client presents with Drag and Drop contractions that she describes as strong in intensity. Her cervical exam indicates that she is dilated to 3 cm. Which conclusion should the nurse make based on this information?
- A. The client is experiencing early labor.
- B. The client is experiencing false labor.
- C. The client has experienced cervical ripening.
- D. The client has experienced lightening.
Correct Answer: A
Rationale: Early labor is a pattern of labor that occurs when contractions become Drag and Drop and the cervix dilates to 3 cm. False labor occurs when Braxton-Hicks contractions are strong enough for the client to believe she is in actual labor. The contractions are infrequent or do not have a definite pattern. The lack of cervical change is also consistent with false labor. The latent phase is characterized by Drag and Drop contractions, although fetal descent may not occur. Cervical ripening (softening, effacement, and increased distensibility) begins about 4 weeks before birth. There is no information in the stem about cervical ripening. Lightening is settling or lowering of the fetus into the pelvis. Lightening can occur a few weeks or a few hours before labor. There is no information in the stem about lightening.
The nurse is reviewing the medication history of the client during preconception counseling. The client reports taking isotretinoin for acne. Which is the nurse’s best response?
- A. “Stop taking isotretinoin now! It can cause serious birth defects if you become pregnant.”
- B. “You need to be on some type of birth control right now. Getting pregnant is not an option.”
- C. “Talk with your HCP about changing isotretinoin before you consider becoming pregnant.”
- D. “Once you are off of isotretinoin for treating acne, you can then safely become pregnant.”
Correct Answer: C
Rationale: The best response is to have the client consult her HCP so another medication can be prescribed. This response indicates that isotretinoin (Accutane) is not safe but that alternative medications can be prescribed. Responding to the client emphatically can create anxiety and fear. Telling the client that getting pregnant is not an option is a paternal response and does not facilitate open communication. Clients must wait one month after cessation of isotretinoin before becoming pregnant.
The continuous electronic FHR monitor tracing on the laboring client is no longer recording. How should the nurse immediately respond?
- A. Conclude that there is a problem with the baby and call for help.
- B. Check that there is adequate gel under the transducer and reposition.
- C. Give the client oxygen via facemask at 8 to 10 liters per minute.
- D. Auscultate fetal heart rate by fetoscope and assess maternal vital signs.
Correct Answer: B
Rationale: When the FHR monitor tracing is no longer recording, the nurse should first check for adequate gel under the transducer. There needs to be adequate gel under the transducer for good conduction, and adding gel frequently corrects the problem. Assessing for adequate gel under the transducer and repositioning should be done before assuming there is a problem with the baby’s HR. There is no indication to give oxygen to the client. Auscultating FHR by fetoscope and assessing maternal VS could be completed, but not until the transducer has been checked.