Nokea
The laboring multigravida client’s last vaginal examination was 8/90/+1. The client now states feeling rectal pressure. Which action should the nurse perform first?
- A. Encourage the client to push.
- B. Notify the obstetrician or midwife.
- C. Help the client to the bathroom.
- D. Complete another vaginal exam.
Correct Answer: D
Rationale: The nurse should first evaluate labor progress by performing another vaginal exam. Previously the client was almost fully effaced (90%), and fetal station was 1 cm below the ischial spines (+1). Rectal pressure is often due to pressure exerted during descent of the fetal presenting part. The client needs to be fully dilated (10 cm, not 8 cm) and fully effaced (100%, not 90%) before being encouraged to push. Pushing too early may cause cervical edema and lacerations and may slow the labor process. Rectal pressure may indicate that the client has progressed since the last vaginal exam. Another vaginal exam should be performed before contacting the obstetrician or midwife. During labor, rectal pressure is usually not due to the need for a bowel movement because intestinal motility decreases.
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The nurse is caring for the Muslim client in labor. What should the nurse be most aware of as a possible belief of the client?
- A. Male health care providers should enter the room after receiving permission from her husband.
- B. The client may prefer to eat only “hot” foods and to drink only special tea and warm water.
- C. Fathers, rather than female relatives, are usually present to provide support during the labor.
- D. She will be more likely to moan, scream, or cry out in pain during each labor contraction.
Correct Answer: A
Rationale: Some Muslim women are not comfortable with male HCPs and may prefer to have their husband in the room if a male is involved in care. Eating “hot” foods and drinking special tea and warm water are preferences of Hmong women from Laos and not those of Muslim women. The Muslim client may choose to have her husband, a male relative, or a female friend or relative provide support during childbirth, rather than her father. Muslim women are more likely to be silent and stoic during labor contractions, and not cry out in pain.
The client is diagnosed with pregnancy-related diabetes at 28 weeks’ gestation. In teaching the client, the nurse includes which information for managing her blood glucose levels? Select all that apply.
- A. Drawing glycosylated hemoglobin A1c levels
- B. Performing home blood glucose monitoring
- C. Developing a weight management plan
- D. Engaging in appropriate daily exercise
- E. Taking oral diabetic agents in the am.
Correct Answer: A,B,C,D
Rationale: Hgb A1c will be drawn and monitored throughout the pregnancy, with a goal of reaching a level of less than 7%. Home blood glucose monitoring will help the client identify when her blood glucose is outside normal parameters. Excessive weight gain worsens control of glucose levels. Exercise adapted for the pregnant body is important to glucose control. Oral diabetic agents are contraindicated in pregnant clients.
Multiple women are being seen in a clinic for various conditions. From which clients should the nurse prepare to obtain a group beta streptococcus (GBS) culture? Select all that apply.
- A. The client who is having symptoms of preterm labor
- B. The women who had a neonatal death 1 year ago
- C. All pregnant women coming to the clinic for care
- D. The women who had a spontaneous abortion 1 week ago
- E. The women who had an abortion for an unwanted pregnancy
Correct Answer: A,C
Rationale: The client in preterm labor should be screened for GBS infection. Between 10% and 30% of all women are colonized for GBS. All pregnant women, regardless of risk status, should be screened for GBS infection. Between 10% and 30% of all women are colonized for GBS. There is no indication that the client with a previous neonatal death is pregnant. The client would not be screened for GBS solely because of a history of spontaneous abortion. The client would not be screened for GBS solely because of an elective abortion.
Which assessment finding best represents a positive sign of pregnancy?
- A. Palpable fetal outline
- B. Blotchy tan facial skin
- C. Positive pregnancy test
- D. Fetal heartbeat
Correct Answer: D
Rationale: A fetal heartbeat, detected by Doppler or ultrasound, is a positive sign of pregnancy, as it directly confirms the presence of a living fetus.
The nurse is assessing the laboring client who is morbidly obese. The nurse is unable to determine the fetal position. Which action should be performed by the nurse to obtain the most accurate method of determining fetal position in this client?
- A. Inspect the client’s abdomen.
- B. Palpate the client’s abdomen.
- C. Perform a vaginal examination.
- D. Perform transabdominal ultrasound.
Correct Answer: D
Rationale: Real-time transabdominal ultrasound (US) is the most accurate assessment measure to determine the fetal position and is frequently available in the birthing setting. US images may be used to assess fetal lie, presentation, and position in the morbidly obese client. Inspection of the abdomen can be used to determine fetal position, but because the client is obese, this is not the most accurate method. Palpation of the abdomen can be used to determine fetal position, but because the client is obese, this is not the most accurate method. Vaginal examination can be used to determine fetal position, but because the client is obese, this is not the most accurate method.