Nokea
The nurse is caring for a client in labor receiving epidural anesthesia. What is the priority nursing assessment?
- A. Assess for bladder distention.
- B. Monitor maternal blood pressure.
- C. Evaluate fetal heart rate.
- D. Check for pain relief.
Correct Answer: B
Rationale: Maternal blood pressure monitoring is essential to detect and manage hypotension, a common side effect of epidural anesthesia.
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Which component is important to include in the sexual history assessment to assess the risk of sexually transmitted infections (STIs)?
- A. current sexual activity
- B. reproductive plans
- C. education and counseling
- D. history of HIV testing
Correct Answer: A
Rationale:
A client at 12 weeks' gestation asks about managing constipation during pregnancy. What is the nurse's best advice?
- A. Take a laxative daily.
- B. Increase fiber intake and fluids.
- C. Avoid physical activity.
- D. Limit vegetable consumption.
Correct Answer: B
Rationale: Increasing dietary fiber and fluids helps relieve constipation, which is common during pregnancy.
A patient who has an LNG-IUC in place calls the office and states she just took a pregnancy test, and it is positive. She comes in for a visit, and the nurse does another pregnancy test, which is positive. What does the nurse know that the clinician will inform the patient regarding the IUC?
- A. Removing the IUC may increase the chance of infertility.
- B. The fetus is at risk for congenital defects.
- C. The IUC needs to be removed regardless of the plans for this pregnancy.
- D. There is no risk to the fetus if the IUC is left in place.
Correct Answer: D
Rationale: The correct statement the nurse knows that the clinician will inform the patient regarding the LNG-IUC is that there is no risk to the fetus if the IUC is left in place. The LNG-IUC (levonorgestrel-releasing intrauterine system) is a highly effective form of contraception that works by releasing progesterone locally in the uterus. The hormonal effect of the LNG-IUC is mostly limited to the uterus and very little of it circulates systemically. Therefore, there is no known increased risk of congenital defects or harm to the fetus if the IUC is left in place during pregnancy. The IUC can be left in place if the patient chooses to continue the pregnancy, provided there are no signs of infection or other complications that would necessitate its removal.
A nurse is caring for a client who is 14 weeks of gestation. At which the following locations should the nurse place the Doppler device when assessing the fetal heart rate?
- A. Midline 2 to 3 cm (0.8 to 1.2 in) above the symphysis pubis
- B. Left Upper Abdomen
- C. Two fingerbreadths above the umbilicus
- D. Lateral at the Xiphoid Process
Correct Answer: A
Rationale: When assessing the fetal heart rate in a client who is 14 weeks of gestation, the nurse should place the Doppler device at the midline 2 to 3 cm above the symphysis pubis. This is the appropriate location for detecting the fetal heartbeat at this gestational age. Placing the Doppler device too high on the abdomen may result in difficulty in detecting the fetal heart rate due to the position of the uterus and fetal size. Placing it too low may not capture the fetal heartbeat accurately. Therefore, the midline location above the symphysis pubis provides the best chance for accurate assessment of the fetal heart rate at 14 weeks of gestation.
A nurse is caring for a client who is receiving oxytocin to augment labor. The nurse notes recurrent variable decelerations...Which of the following actions should the nurse take first?
- A. Prepare the equipment necessary to initiate an amnioinfusion.
- B. Administer oxygen at 10 L/min via nonrebreather face mask.
- C. Discontinue the infusion of oxytocin.
- D. Place the client in a left lateral position.
Correct Answer: C
Rationale: Recurrent variable decelerations during labor can indicate umbilical cord compression, which can result in fetal hypoxia and distress. Discontinuing the oxytocin infusion is the priority in this situation as oxytocin can cause or exacerbate uteroplacental insufficiency leading to fetal distress. By discontinuing the oxytocin, the nurse can help improve fetal oxygenation and alleviate the variable decelerations. After stopping the oxytocin infusion, the nurse should continue to monitor the fetal heart rate pattern and follow the healthcare provider's orders for further management if needed.