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The nurse is monitoring a client with hypertonic uterine contractions. What is the priority nursing action?
- A. Administer pain relief as prescribed.
- B. Prepare for an amniotomy.
- C. Encourage ambulation.
- D. Increase oxytocin infusion.
Correct Answer: A
Rationale: The correct answer is A: Administer pain relief as prescribed. The priority is to address the client's discomfort and pain caused by hypertonic uterine contractions. Pain management is crucial to ensure the client's comfort and well-being. Administering pain relief can help prevent complications such as increased stress on the mother and fetus.
Choice B: Prepare for an amniotomy is incorrect because it involves artificial rupturing of the amniotic sac, which is not indicated for hypertonic contractions.
Choice C: Encourage ambulation is incorrect because it may exacerbate the pain and discomfort experienced by the client with hypertonic uterine contractions.
Choice D: Increase oxytocin infusion is incorrect because it can further intensify the uterine contractions and worsen the client's pain.
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The nurse is reviewing a prenatal client’s record. Which history finding increases the risk for preeclampsia?
- A. Advanced maternal age.
- B. History of gestational diabetes.
- C. First pregnancy.
- D. History of anemia.
Correct Answer: C
Rationale: The correct answer is C: First pregnancy. Preeclampsia is more common in first pregnancies due to the body's lack of adaptation to the pregnancy. In subsequent pregnancies, the body has already gone through the changes necessary for pregnancy, reducing the risk. Advanced maternal age (A) and history of gestational diabetes (B) are risk factors for other pregnancy complications but not specifically preeclampsia. History of anemia (D) is not directly linked to an increased risk of preeclampsia.
The nurse is monitoring a client in labor and suspects hypertonic uterine contractions. What is the priority nursing action?
- A. Provide pain relief measures.
- B. Prepare the client for an amniotomy.
- C. Promote ambulation every 30 minutes.
- D. Monitor the oxytocin infusion closely.
Correct Answer: A
Rationale: The correct answer is A: Provide pain relief measures. In hypertonic uterine contractions, the uterus contracts too frequently and intensely, leading to increased pain and potential fetal distress. Providing pain relief helps alleviate discomfort for the client and may reduce the risk of fetal distress. Other choices are incorrect because: B) Amniotomy may not be necessary and could potentially worsen the situation. C) Ambulation may not be safe or effective during hypertonic contractions. D) Monitoring the oxytocin infusion closely is important but not the priority in managing hypertonic contractions.
A client at 30 weeks' gestation is receiving magnesium sulfate for preterm labor. What assessment finding indicates magnesium toxicity?
- A. Deep tendon reflexes +3.
- B. Respiratory rate of 10 breaths per minute.
- C. Urine output of 40 mL/hour.
- D. Blood pressure of 120/80 mmHg.
Correct Answer: B
Rationale: The correct answer is B: Respiratory rate of 10 breaths per minute. Magnesium sulfate toxicity can lead to respiratory depression, resulting in a decreased respiratory rate. This is a critical sign of magnesium toxicity and should be addressed promptly.
Explanation for other choices:
A: Deep tendon reflexes +3 are actually a common finding in clients receiving magnesium sulfate due to its muscle relaxant effects.
C: Urine output of 40 mL/hour is within the normal range and does not indicate magnesium toxicity.
D: Blood pressure of 120/80 mmHg is also within the normal range and is not a sign of magnesium toxicity.
A nurse is caring for a client who is at 40 weeks gestation and is in active labor. The client has 6 cm of cervical dilation and 100% cervical effacement. The nurse obtains the client's blood pressure reading as 82/52 mm Hg. Which of the following nursing interventions should the nurse perform?
- A. Prepare for a cesarean birth.
- B. Assist the client to an upright position.
- C. Prepare for an immediate vaginal delivery.
- D. Assist the client to turn onto her side.
Correct Answer: D
Rationale: Correct Answer: D - Assist the client to turn onto her side.
Rationale:
1. Side-lying position improves placental perfusion and circulation, optimizing blood pressure.
2. This position also helps in relieving pressure on major blood vessels, preventing hypotension.
3. It is a non-invasive intervention that can be quickly implemented in the labor setting.
Summary of Other Choices:
A: Preparing for a cesarean birth is not indicated based solely on the client's blood pressure reading.
B: Assisting the client to an upright position may further decrease blood pressure and compromise perfusion.
C: Immediate vaginal delivery is not warranted solely based on the client's blood pressure and cervical dilation.
16wks gestation reports for a triple screen test. What statements determines understanding?
- A. "This test can be used as a screening for spina bifida."
- B. "This test is a screen test, and I will need other testing if I have abn results."
- C. "this test can indicate if I may be at an increased risk for having a child with down syndrome."
- D. A triple screen test is a screening tool. Maternal blood is drawn and alpha-fetoprotein, hcg, and estriol values are assessed to determine if the mother is at an increased risk for neural tube defects or chromosomal trisomy's. Spina bifida and downs syndrome are the two most common risks.
Correct Answer: D
Rationale: Step-by-step rationale for why answer D is correct:
1. A triple screen test includes assessing alpha-fetoprotein, hCG, and estriol levels.
2. These values help determine the risk for neural tube defects and chromosomal trisomies.
3. The test does not directly diagnose spina bifida but assesses neural tube defects.
4. Down syndrome risk is also evaluated, not diagnosed directly.
5. Answer D provides a comprehensive explanation of the test components and its purpose, aligning with the test's actual function.
Summary of why other choices are incorrect:
A. Incorrect because the test screens for neural tube defects and chromosomal trisomies, not just spina bifida.
B. Incorrect because the test is a screening tool for specific conditions, not a definitive diagnostic test.
C. Incorrect because the test assesses multiple conditions, not just Down syndrome specifically.