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The laboring client presents with ruptured membranes, frequent contractions, and bloody show. She reports a greenish discharge for 2 days. Place the nurse’s actions in the order that they should be completed.
- A. Perform a sterile vaginal exam
- B. Assess the client thoroughly
- C. Obtain fetal heart tones
- D. Notify the health care provider
Correct Answer: C,A,B,D
Rationale: Obtain FHT should be first. The client has ruptured membranes with greenish fluid, and the fetus could be experiencing nonreassuring fetal status. Perform a sterile vaginal exam to determine labor progression. Assess the client thoroughly. This needs to be completed prior to notifying the HCP with the information. Notify the HCP is last of the options. Assessment findings would need to be reported to the HCP. The client should then be moved into an inpatient room.
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The nurse’s laboring client is being electronically monitored during her labor. The baseline FHR throughout the labor has been in the 130s. In the last 2 hours, the baseline has decreased to the 100s. How should the nurse document this FHR?
- A. Tachycardia
- B. Bradycardia
- C. Late deceleration
- D. Within normal limits
Correct Answer: B
Rationale: An FHR baseline less than 110 is classified as bradycardia. Tachycardia occurs when the baseline is greater than 160 bpm. A prolonged deceleration is defined as a change from the baseline FHR that occurs for 2 to 10 minutes before returning to baseline. A late deceleration is a gradual decrease and return of the FHR to baseline, associated with a uterine contraction. A decrease to the 100s is not within the normal range. The normal FHR is 120 to 160 bpm.
The nurse notifies the HCP after feeling a pulsating mass during the vaginal examination of a newly admitted full-term pregnant client. Which HCP order should the nurse question?
- A. Prepare for possible cesarean section.
- B. Place the client in a knee-chest position.
- C. Initiate a low-dose oxytocin IV infusion.
- D. Give terbutaline 0.25 mg subcutaneously.
Correct Answer: C
Rationale: The nurse should question the administration of oxytocin (Pitocin). Oxytocin is used for stimulating contraction of the uterus. Uterine contractions can cause further umbilical cord compression. The pulsating mass indicates umbilical cord prolapse, which is a medical emergency. If vaginal birth is not imminent, a cesarean section is preferred in order to prevent hypoxic acidosis. Placing the client in a knee-chest position relieves pressure on the umbilical cord. Terbutaline (Brethine) is a tocolytic agent used to reduce contractions.
After delivering the full-term infant, the breastfeeding mother asks the nurse if there is any contraceptive method that she should avoid while she is breastfeeding. Which contraceptive should the nurse advise the client to avoid?
- A. A diaphragm
- B. An intrauterine device (IUD)
- C. The combined oral contraceptive (COC) pill
- D. The progesterone-only mini pill
Correct Answer: C
Rationale: Because a diaphragm must be fitted to the individual female cervix, the diaphragm must be rechecked for correct size after each childbirth; however, use of the diaphragm will not affect breast milk production. An IUD will not affect breast milk production unless the IUD is inserted within the first 48 hours postpartum; insertion should be delayed until 4 weeks postpartum. Birth control pills containing progesterone and estrogen (COC) can cause a decrease in milk volume and may affect the quality of the breast milk. The progesterone-only mini pill may be used by breastfeeding clients because it does not interfere with breast milk production. However, it is recommended that the mother wait 6 to 8 weeks before starting this method of contraception.
Which resource should the nurse recommend for additional prenatal education?
- A. Reputable pregnancy websites
- B. Social media forums
- C. Unverified blogs
- D. Television advertisements
Correct Answer: A
Rationale: Reputable pregnancy websites provide evidence-based information, ensuring accurate and reliable prenatal education.
The client is diagnosed with moderate postpartum depression (PPD) after vaginal delivery of a 10 lb baby. One week following the delivery, the nurse is completing a home visit. Which finding should be the nurse’s priority?
- A. Lochia has a foul-smelling odor.
- B. Small but tender hemorrhoids.
- C. Yells at her baby to stop crying.
- D. Client cries throughout the visit.
Correct Answer: C
Rationale: Lochia that is foul smelling could indicate that the client has a postpartum infection. The client needs to be seen by an HCP, but the safety of the infant is priority. The presence of tender hemorrhoids may be uncomfortable and should be addressed, but this is not priority. It is inappropriate for the client to yell at her baby to stop crying. Verbal abuse can escalate to physical abuse. The safety of the infant should be the nurse’s priority. Persistent crying is a sign of PPD and would be expected. However, persistent crying should be further explored because treatment may be ineffective.