Nokea
The nurse is caring for a client in the postpartum period. What finding indicates a need for immediate intervention?
- A. Fundus firm and midline.
- B. Lochia rubra with large clots.
- C. Perineal pain after delivery.
- D. Slight swelling of the feet.
Correct Answer: B
Rationale: Large clots in lochia rubra may indicate retained placental fragments or postpartum hemorrhage.
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A nurse is caring for a client who is receiving oxytocin to augment labor. The client has an intrauterine pressure catheter and an internal fetal scalp electrode for monitoring. Which of the following is an indication that the nurse should discontinue the infusion?
- A. Contraction frequency every 3 min
- B. Contraction duration of 100 seconds
- C. Fetal heart rate with moderate
- D. variability Fetal heart rate of 118/min
Correct Answer: B
Rationale: Prolonged contractions lasting more than 90-120 seconds may reduce placental perfusion and oxygenation to the fetus, leading to fetal distress. This can result in fetal hypoxia and compromise. Therefore, if the contraction duration reaches 100 seconds, it is an indication for the nurse to discontinue the oxytocin infusion to prevent harm to the fetus. Monitoring for appropriate contraction duration is crucial to ensure the well-being of both the mother and the fetus during labor. While contraction frequency every 3 minutes, a fetal heart rate with moderate variability, and a fetal heart rate of 118/min can be normal findings during labor, a prolonged contraction duration is a concerning sign that requires immediate intervention.
A client at 34 weeks' gestation is diagnosed with polyhydramnios. What is the nurse's priority assessment?
- A. Monitor maternal blood pressure.
- B. Assess for signs of preterm labor.
- C. Check for signs of infection.
- D. Evaluate for fetal heart rate changes.
Correct Answer: B
Rationale: Polyhydramnios increases the risk of preterm labor due to uterine overdistension, requiring close monitoring.
The nurse is educating a male patient on how a vasectomy works. What is the best explanation for this procedure?
- A. The procedure blocks the sperm from entering into the semen and being ejaculated.
- B. The procedure removes the testicle so that sperm are not made.
- C. The tube that carries seminal fluid is blocked, causing no semen to be ejaculated.
- D. The procedure kills all sperm so they are unable to make it to the ovulated egg.
Correct Answer: A
Rationale: A vasectomy involves blocking or cutting the vas deferens to prevent sperm from being ejaculated with semen, making it an effective method of contraception. Choice B is incorrect because the testicles are not removed during a vasectomy, only the vas deferens is altered. Choice C is incorrect because seminal fluid is still produced, but sperm are prevented from entering it. Choice D is incorrect because sperm are not killed, but rather prevented from mixing with semen.
The nurse received end of shift report in a high-risk maternity unit. Which patient should the nurse see first?
- A. 26 weeks with placenta previa experiencing blood on toilet tissue after bowel movement (placenta is getting lower)
- B. 30 weeks' gestation with placenta previa whose fetal monitor shows late decelerations
- C. 35 weeks' gestation with grade I abruptio placenta in labor who has strong urge to push
- D. 37 weeks' gestation with pregnancy induced hypertension whose membrane ruptured spontaneously
Correct Answer: C
Rationale: The patient who should be seen first is the 35 weeks' gestation with grade I abruptio placenta in labor who has a strong urge to push. Abruptio placenta is a serious condition where the placenta detaches from the uterine wall before delivery, leading to significant bleeding and potential compromise to both the mother and baby. The strong urge to push indicates that the baby is in distress and immediate intervention is required to prevent potential harm. This patient needs urgent assessment and intervention to ensure the safety of both the mother and the baby.
The nurse is caring for a client in labor with meconium-stained amniotic fluid. What is the priority action?
- A. Administer oxygen to the mother.
- B. Notify the healthcare provider.
- C. Prepare for potential neonatal resuscitation.
- D. Increase IV fluid rate.
Correct Answer: C
Rationale: Meconium-stained amniotic fluid poses a risk of aspiration; preparation for neonatal resuscitation is critical.