Nokea
The nurse advises the client to practice which technique to cope with labor pain?
- A. Lamaze breathing
- B. Holding her breath
- C. Tensing muscles
- D. Avoiding movement
Correct Answer: A
Rationale: Lamaze breathing helps manage labor pain by promoting relaxation and focus, unlike tensing or breath-holding.
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The client in active labor has moderate to strong contractions occurring every 2 minutes and lasting 60 to 70 seconds. The client states extreme pain in the small of her back. Her abdomen reveals a small depression under the umbilicus. Which fetal position should the nurse document?
- A. Occiput anterior
- B. Occiput posterior
- C. Left occiput anterior
- D. Right occiput anterior
Correct Answer: B
Rationale: An occiput posterior position is characterized by intense back pain (back labor). A depression under the umbilicus occurs as a result of the posterior shoulder. When a fetus presents anterior, it is uncommon for the mother’s chief symptom to be back pain, and the uterus should appear smooth.
The nurse is doing a one-minute Apgar score on a newborn and tells the parents that it is 7 points. When the parents ask what this means, how should the nurse best respond?
- A. “This score is good, but the baby needs to have a score of 10 in five minutes.”
- B. “The Apgar score can predict intelligence and neurological development.”
- C. “Your baby is fine and should have no difficulty adapting outside the womb.”
- D. “Your baby has good vital signs and is classified as full-term gestational age.”
Correct Answer: C
Rationale: This response is best because a score of 7 to 10 is within a normal range and 并表示新生儿没有任何不适的迹象。A score of 7 to 10 is considered acceptable for a one-minute Apgar. However, when the scoring is repeated at 5 minutes of age, a score of 7 to 10, not just 10, is within normal range. The Apgar score is used to systematically assess an infant at one and five minutes after birth to determine if immediate care is necessary. It is not used to predict intelligence or neurological development. Although the Apgar score does mean that the newborn’s VS are WNL, the Apgar score is not designed to classify gestational age.
The nurse advises the client that this test is typically performed at what time during the pregnancy?
- A. Just after the pregnancy is confirmed
- B. Early in the second trimester
- C. In the transition phase of labor
- D. Just after the first fetal movements
Correct Answer: B
Rationale: Amniocentesis is typically performed early in the second trimester (15-20 weeks) to assess for genetic abnormalities.
The nurse just administered butorphanol tartrate as prescribed to the client in active labor. Following administration of butorphanol tartrate, what is the nurse’s most important action to help prevent side effects?
- A. Assess the client’s bladder for distention
- B. Place the client on seizure precautions
- C. Assess the client’s body for itchy rash
- D. Evaluate her vital signs and pulse oximetry
Correct Answer: D
Rationale: Evaluating maternal VS and pulse oximetry would determine changes in respiratory and cardiac status. Respiratory depression in both the mother and fetus can occur with butorphanol tartrate (Stadol). Although bladder distention is a possible side effect of butorphanol tartrate, it is not common and is not the most important assessment. Seizures are not a potential side effect of butorphanol tartrate. An itchy rash is not a potential side effect of butorphanol tartrate.
Which finding indicates a need for further evaluation during a prenatal visit?
- A. Blood pressure of 120/80 mmHg
- B. Trace protein in urine
- C. Weight gain of 1 pound per week
- D. Fetal heart rate of 140 bpm
Correct Answer: B
Rationale: Trace protein in urine may indicate early preeclampsia or kidney issues, warranting further evaluation.