Nokea
The laboring client just had a convulsion after being given regional anesthesia. Which interventions should the nurse implement? Select all that apply.
- A. Establish an airway.
- B. Position on her right side.
- C. Provide 100% oxygen.
- D. Administer diazepam.
- E. Page the anesthesiologist STAT.
Correct Answer: A,C,D,E
Rationale: The client experiencing a convulsion related to anesthesia should first have an airway established. The client experiencing a convulsion related to anesthesia should receive 100% oxygen so that the mother and fetus remain oxygenated. Small doses of diazepam or thiopental can be administered to stop the convulsions. The anesthesiologist should be STAT paged to provide assistance; the convulsion was initiated by the regional anesthetic. The client’s head should be turned to the side if vomiting occurs, but the client typically remains in a left lateral tilt position so an airway can be maintained. Positioning on the right side can cause aortocaval compression.
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The laboring client’s amniotic membranes have just ruptured. Which nursing action should be priority?
- A. Monitor maternal temperature.
- B. Inspect characteristics of the fluid.
- C. Perform a sterile vaginal examination.
- D. Assess the fetal heart rate pattern.
Correct Answer: D
Rationale: The priority nursing action is to assess the FHR pattern for several minutes immediately after membrane rupture to determine fetal well being. The umbilical cord may prolapse as a result of the rupture, causing life-threatening changes in the FHR. The maternal temperature should be monitored during labor and at least every two hours after the membranes rupture to assess for possible infection. However, this is not the priority nursing action. Characteristics of the fluid (color, odor, and estimated amount) should be assessed and documented after rupture, but this is not the priority at this time. A vaginal exam that assesses the progress of labor does need to be performed right after membrane rupture, but it is not the priority.
In the primigravid client, when is fetal movement typically felt for the first time?
- A. Between 10 and 14 weeks' gestation
- B. Between 16 and 20 weeks' gestation
- C. Between 22 and 26 weeks' gestation
- D. Between 28 and 32 weeks' gestation
Correct Answer: B
Rationale: Primigravid women typically feel fetal movement (quickening) between 16 and 20 weeks, later than multigravida women.
The nurse assesses the client in her third trimester with suspected placenta previa. Which finding should the nurse associate with placenta previa?
- A. Cervix is 100% effaced
- B. Painless vaginal bleeding
- C. The fetal lie is transverse
- D. Absence of fetal movement
Correct Answer: B
Rationale: In placenta previa, the abnormal location of the placenta causes painless, bright red vaginal bleeding as the lower uterine segment stretches and thins. The nurse should not perform a vaginal examination to determine effacement on the client with suspected placenta previa. The lie of the fetus is not associated with placenta previa. An absence of fetal movement is always cause for concern but is not a primary symptom of placenta previa.
The nurse teaches the client to monitor which newborn condition?
- A. Umbilical cord stump for infection
- B. Daily weight gain over 1 pound
- C. Frequent crying as abnormal
- D. No bowel movements for a week
Correct Answer: A
Rationale: Monitoring the umbilical cord stump for infection (redness, discharge) is critical for newborn health.
The client tells the nurse that she is using cocoa butter on her abdomen to prevent stretch marks. Which is the most accurate response from the nurse?
- A. “That is wonderful. If you continue to use cocoa butter daily, you should have no stretch marks after delivery.”
- B. “The cocoa butter will not prevent stretch marks completely, but it will help to reduce their number.”
- C. “The cocoa butter will not prevent stretch marks but will decrease the appearance of the linea nigra.”
- D. “Cocoa butter does not prevent stretch marks, but it soothes itching that occurs as your abdomen enlarges.”
Correct Answer: D
Rationale: Cocoa butter is an emollient and provides moisture to the skin, thereby decreasing the itching associated with stretching of the skin as the abdomen enlarges. Cocoa butter does not prevent striae gravidarum. Cocoa butter does not decrease the incidence of striae gravidarum. Cocoa butter does not prevent the appearance of linea nigra.