Nokea
The primigravida is admitted to the birthing and labor unit, but
- A. The initial response from the nurse will be to:
- B. Take health history
- C. Perform vaginal exam
- D. Review prenatal record
Correct Answer: B
Rationale: The correct answer is B: Take health history. This is the initial response because obtaining the patient's health history provides crucial information about the primigravida's medical background, current health status, any complications, and helps in assessing the risk factors for labor and delivery. This information guides the nurse in providing appropriate care and making informed decisions during the labor process.
Choice A (The initial response from the nurse will be to) is vague and not specific enough to address the immediate needs of the patient.
Choice C (Perform vaginal exam) is not appropriate as the first action because it can be invasive and should only be performed after obtaining the health history to determine the necessity and timing of the exam.
Choice D (Review prenatal record) is important but should come after taking the health history to supplement the information obtained and provide a comprehensive understanding of the patient's pregnancy course.
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A young girl comes to the OB-GYN office to begin contraception. What is the most important information the nurse should find in the history before starting a contraceptive?
- A. Do your cramps prevent you from daily activities?
- B. When was your last menstrual period?
- C. How much water do you drink?
- D. How many pads do you soak per day during your cycle?
Correct Answer: A
Rationale: The correct answer is A: "Do your cramps prevent you from daily activities?" This question is crucial as it assesses the impact of menstrual cramps on the girl's quality of life, helping determine the suitability of different contraceptive options. Options B, C, and D are irrelevant to contraceptive choice and do not provide pertinent information regarding the girl's health or contraceptive needs.
A nurse is planning care for a client who is receiving oxytocin by continuous IV infusion for labor induction. Which of the following interventions should the nurse include in the plan?
- A. Increase the infusion rate every 30 to 60 min.
- B. Maintain the client in a supine position.
- C. Titrate the infusion rate by 4 milliunits/min.
- D. Limit IV intake to 4 L per 24 hr.
Correct Answer: C
Rationale: The correct answer is C: Titrate the infusion rate by 4 milliunits/min. This is the appropriate intervention because oxytocin is a potent uterotonic agent used for labor induction. By titrating the infusion rate by 4 milliunits/min, the nurse can closely monitor and adjust the dose to achieve the desired uterine contractions without causing hyperstimulation. Increasing the infusion rate every 30 to 60 min (A) can lead to rapid and uncontrolled contractions. Maintaining the client in a supine position (B) can decrease blood flow to the placenta. Limiting IV intake to 4 L per 24 hr (D) is not necessary and may lead to dehydration.
Induction of labor is planned for 31-year-old primigravida 39 weeks. She has insulin dependent diabetes. Which nursing action is more important?
- A. Begin Pitocin 4h after Cytotec (thin the cervix first)
- B. Administer 100mcg Cytotec q2h(no)
- C. Place vaginal gel and ambulate patient 1h
- D. Prepare to induce labor after administering tap water enema
Correct Answer: A
Rationale: The correct answer is A: Begin Pitocin 4h after Cytotec. This is the most important nursing action because it follows the recommended protocol for inducing labor in a diabetic patient. Cytotec is used to thin the cervix, and waiting 4 hours before starting Pitocin reduces the risk of uterine hyperstimulation, which can be dangerous for the mother and baby. Administering Cytotec every 2 hours (choice B) can increase the risk of hyperstimulation. Placing vaginal gel and ambulating the patient (choice C) may not be appropriate in this case as the patient has diabetes. Preparing to induce labor after administering a tap water enema (choice D) is not a priority compared to ensuring a safe induction process for a diabetic patient.
What can self-awareness with postural adjustments lead to?
- A. tension formation
- B. tension release
- C. suboptimal posture
- D. back pain
Correct Answer: B
Rationale: Self-awareness with postural adjustments can lead to tension release because it allows individuals to identify and correct any muscular imbalances or poor postural habits. By being aware of their body positioning and making necessary adjustments, individuals can reduce muscle tension and promote proper alignment, leading to relaxation and alleviation of tension. This proactive approach helps prevent the buildup of tension in muscles, ultimately promoting overall well-being.
Incorrect Choices:
A: Tension formation - Self-awareness with postural adjustments helps prevent tension formation by addressing imbalances.
C: Suboptimal posture - Self-awareness promotes optimal posture by making adjustments.
D: Back pain - Proper postural adjustments can alleviate back pain, not cause it.
A client at 36 weeks' gestation reports severe itching without a rash. What condition should the nurse suspect?
- A. Cholestasis of pregnancy.
- B. Preeclampsia.
- C. Gestational diabetes.
- D. Intrauterine growth restriction.
Correct Answer: A
Rationale: The correct answer is A: Cholestasis of pregnancy. Severe itching without a rash in a pregnant client at 36 weeks' gestation is often indicative of cholestasis of pregnancy, a liver condition that can occur during pregnancy. This condition is characterized by reduced bile flow, leading to the accumulation of bile acids in the blood, resulting in itching, especially on the palms and soles of the feet. Other choices (B) Preeclampsia, (C) Gestational diabetes, and (D) Intrauterine growth restriction are not typically associated with severe itching without a rash in the absence of other specific symptoms. Preeclampsia presents with hypertension and proteinuria, gestational diabetes with high blood sugar levels, and intrauterine growth restriction with poor fetal growth.