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The nurse is caring for a multigravida client in active labor with continuous epidural anesthesia. When the client is 7 cm dilated, her blood pressure drops to 90/50 mm Hg, and the fetal heart rate shows signs of decelerations. What action should the nurse take first?
- A. Place the client in a lateral position.
- B. Administer oxygen via face mask.
- C. Increase the rate of IV fluid infusion.
- D. Notify the healthcare provider.
Correct Answer: A
Rationale: Placing the client in a lateral position can improve venous return and blood pressure, addressing both maternal hypotension and fetal distress.
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The nurse is writing an expected outcome for the nursing diagnosis—acute pain related to tissue trauma, secondary to vaginal birth, as evidenced by patient stating pain of 8 on a scale of 10. Which expected outcome is correctly stated for this problem?
- A. Patient will state that pain is a 2 on a scale of 10.
- B. Patient will have a reduction in pain after administration of the prescribed analgesic.
- C. Patient will state an absence of pain 1 hour after administration of the prescribed analgesic.
- D. Patient will state that pain is a 2 on a scale of 10, 1 hour after the administration of the prescribed analgesic.
Correct Answer: D
Rationale: The outcome should be patient-centered, measurable, realistic, and attainable within a specified timeframe.
A pregnant patient's diet may not meet her need for folate. Which food choice is an excellent source of this nutrient?
- A. Chicken
- B. Cheese
- C. Potatoes
- D. Green leafy vegetables
Correct Answer: D
Rationale: The correct answer is D: Green leafy vegetables. Green leafy vegetables such as spinach, kale, and broccoli are excellent sources of folate, a crucial nutrient for pregnant women to prevent neural tube defects in the fetus. These vegetables are rich in natural folate, making them an ideal choice for meeting the increased folate requirements during pregnancy. Chicken (A), cheese (B), and potatoes (C) do not contain as high levels of folate as green leafy vegetables, making them less optimal choices for ensuring adequate intake of this essential nutrient during pregnancy.
Regarding advanced roles of nursing, which statement related to clinical practice is the most accurate?
- A. Family nurse practitioners (FNPs) can assist with childbirth care in the hospital setting.
- B. Clinical nurse specialists (CNSs) provide primary care to obstetric patients.
- C. Neonatal nurse practitioners provide emergency care in the postbirth setting to high-risk infants.
- D. A certified nurse midwife (CNM) is not considered to be an advanced practice nurse.
Correct Answer: C
Rationale: Neonatal NPs provide specialized care for high-risk neonates in the birth room and NICU as needed.
A 42-week gestational client is receiving an intravenous infusion of oxytocin (Pitocin) to augment early labor. The nurse should discontinue the oxytocin infusion for which pattern of contractions?
- A. Transition labor with contractions every 2 minutes, lasting 90 seconds each
- B. Early labor with contractions every 5 minutes, lasting 40 seconds each
- C. Active labor with contractions every 31 minutes, lasting 60 seconds each
- D. Active labor with contractions every 2 to 3 minutes, lasting 70 to 80 seconds each
Correct Answer: A
Rationale: Contractions pattern (A) describes hyperstimulation and an inadequate resting time between contractions to allow for placental perfusion. The oxytocin infusion should be discontinued.
The nurse is caring for a woman with a previously diagnosed heart disease who is in the second stage of labor. Which assessment findings are of greatest concern?
- A. Edema, basilar rales, and an irregular pulse.
- B. Increased urinary output, and tachycardia.
- C. Dyspnea, bradycardia, and hypertension.
- D. Regular heart rate, and hypertension.
Correct Answer: A
Rationale: Edema, basilar rales, and an irregular pulse indicate potential cardiac decompensation, which is of greatest concern in a woman with heart disease during labor.