Nokea
The nurse assesses a primiparous client in labor for 20 hours. The nurse identifies late decelerations on the monitor and initiates standard procedures for the labor client with this wave pattern. Which intravenous should the nurse perform? Select all that apply.
- A. Administering oxygen via mask to the client.
- B. Questioning the client about the effectiveness of pain relief.
- C. Placing the client on her side.
- D. Readjusting the monitor to a more comfortable position.
- E. Applying an internal fetal monitor to help identify the cause of the decelerations.
Correct Answer: A,C
Rationale: Late decelerations indicate uteroplacental insufficiency. Standard interventions include administering oxygen to improve fetal oxygenation and placing the client on her side to enhance uterine perfusion. Questioning pain relief or readjusting the monitor does not address the issue, and internal monitoring may be considered but is not the first step.
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When developing the plan of care for a multigravid client with class III heart disease, which of the following areas should the nurse expect to assess frequently?
- A. Dehydration.
- B. Nausea and vomiting.
- C. Iron-deficiency anemia.
- D. Tachycardia.
Correct Answer: D
Rationale: Class III heart disease indicates significant cardiac limitation, making tachycardia a critical sign of cardiac stress during labor. Frequent assessment ensures early detection of decompensation. Dehydration, nausea, or anemia are less immediate concerns.
A preterm neonate admitted to the neonatal intensive care unit at about 30 weeks' gestation is placed in an oxygenated isolette. The neonate's mother tells the nurse that she was planning to breast-feed the neonate. Which of the following instructions about breast-feeding would be most appropriate?
- A. Breast-feeding is not recommended because the neonate needs increased fat in the diet.
- B. Once the neonate no longer needs oxygen and continuous monitoring, breast-feeding can be done.
- C. Breast-feeding is contraindicated because the neonate is preterm.
- D. Gavage feedings using breast milk can be given until the neonate can coordinate sucking and swallowing.
Correct Answer: D
Rationale: Gavage feedings with breast milk allow the neonate to receive the benefits of breast milk while accommodating their immature sucking and swallowing reflexes.
A primigravida admitted to the hospital with a diagnosis of hyperemesis gravidarum is placed on nothing-by-mouth(NPO) status and is receiving intravenous(IV) fluid replacement therapy. In planning this client's care, the nurse should collaborate with the health care provider(HCP) to carry out which of the following?
- A. Withhold oral fluids indefinitely until acidosis is corrected.
- B. Give oral fluids in small quantities whenever the client desires.
- C. Per HCP orders, provide clear liquids by mouth after 24 hours if vomiting subsides.
- D. Withhold oral fluids until total parenteral nutrition replaces lost electrolytes.
Correct Answer: C
Rationale: Gradual reintroduction of oral fluids is appropriate once vomiting subsides.
A 28-year-old multigravid client at 28 weeks' gestation diagnosed with acute pyelonephritis is receiving intravenous fluids and antibiotics. After teaching the client about the rationale for the aggressive therapy, the nurse determines that the client needs further instruction when she says that acute pyelonephritis can lead to which of the following?
- A. Preterm labor.
- B. Maternal sepsis.
- C. Intrauterine growth retardation.
- D. Congenital fetal anomalies.
Correct Answer: D
Rationale: Acute pyelonephritis can cause preterm labor, maternal sepsis, and intrauterine growth retardation due to infection and inflammation. Congenital fetal anomalies are not a direct consequence, indicating a need for further teaching.
A 25-year-old primiparous client who delivered a viable neonate 2 hours ago has decided to breast-feed her neonate. Which of the following instructions should the nurse address as the highest priority in the teaching plan about preventing nipple soreness?
- A. Keeping plastic liners in the brassiere to keep the nipple drier.
- B. Placing as much of the areola as possible into the baby's mouth.
- C. Smoothly pulling the nipple out of the mouth after 10 minutes.
- D. Removing any remaining milk left on the nipple with a soft washcloth.
Correct Answer: B
Rationale: Proper latch with the areola in the baby's mouth prevents nipple soreness by reducing trauma.