Nokea
The nurse has obtained a urine specimen from a G 6, P 5 client admitted to the labor unit. The woman asks to go to the bathroom and reports that she feels she has to move her bowels. Which actions would be appropriate? Select all that apply.
- A. Assisting her to the bathroom.
- B. Applying an external fetal monitor to obtain fetal heart rate.
- C. Assessing her stage of labor.
- D. Asking if she had back labor pains like this with any of her other deliveries.
- E. Allowing her support person to take her to the bathroom to maintain privacy.
- F. Checking the degree of fetal descent.
Correct Answer: C,F
Rationale: The urge to move bowels often indicates advanced labor or fetal descent in a multiparous client. Assessing the stage of labor and fetal descent (via vaginal exam) confirms progression and prevents unattended delivery. Assisting to the bathroom or relying on a support person risks delivery, and fetal monitoring or past labor history are secondary.
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Assessment of a term neonate at 8 hours after birth reveals tachypnea, dyspnea, sternal retractions, diminished femoral pulses, poor lower body perfusion, and cyanosis of the lower body and extremities, with a pink upper body. The nurse notifies the pediatrician based on the interpretation that these symptoms are associated with which of the following:
- A. Coarctation of the aorta.
- B. Atrioventricular septal defect.
- C. Pulmonary atresia.
- D. Transposition of the great arteries.
Correct Answer: A
Rationale: These symptoms are characteristic of coarctation of the aorta, which causes reduced blood flow to the lower body.
A female neonate delivered vaginally at term with a cleft lip and cleft palate is admitted to the regular nursery. Which of the following actions should the nurse do the first time that the parents visit the neonate in the nursery?
- A. Explain the surgical interventions that will be performed.
- B. Stress that this defect is not life-threatening.
- C. Emphasize the neonate's normal characteristics.
- D. Reassure the parents about the success rate of the surgery.
Correct Answer: C
Rationale: Emphasizing the neonate's normal characteristics helps promote bonding and reduces parental anxiety during the initial visit.
A client asks about the risks of the contraceptive injection. Which of the following would the nurse include?
- A. Increased risk of blood clots.
- B. Decreased bone density with long-term use.
- C. Permanent weight loss.
- D. Guaranteed regular periods.
Correct Answer: B
Rationale: The contraceptive injection may decrease bone density with long-term use, which is a significant risk. It does not significantly increase blood clot risk, cause permanent weight loss, or guarantee regular periods.
A preterm neonate is unable to breast- or bottle-feed. The physician writes an order to feed the neonate via nasogastric (NG) tube. When choosing an NG feeding tube for a neonate, the nurse should base the tube size on the neonate's:
- A. Disease process.
- B. Gestational age.
- C. Length.
- D. Weight.
Correct Answer: B
Rationale: Gestational age determines the appropriate NG tube size, as it correlates with the neonate's anatomical development.
Assessment of a 23-year-old primigravid client at term who is admitted to the birthing unit in active labor reveals that her cervix is 4 cm dilated and 100% effaced. Contractions are occurring every 4 minutes. The nurse is developing a care plan with the client to relieve pain based on the gate-control theory of pain. The nurse should explain which of the following to the client?
- A. Input from the large sensory fibers opens the gate.
- B. Labor pain is a matter of individual perception.
- C. Slow abdominal breathing can open the gate.
- D. The gating mechanism is in the spinal cord.
Correct Answer: D
Rationale: The gate-control theory posits that pain signals are modulated in the spinal cord, where non-painful stimuli (e.g., touch) can 'close the gate' to pain transmission. Input from large fibers closes the gate, perception varies but is not the mechanism, and slow breathing helps manage pain but does not open the gate.