Nokea
The nurse is caring for a primigravid client in active labor at 42 weeks' gestation. The client has had no analgesia or anesthesia and has been pushing for 2 hours. The nurse can be most helpful to this client by:
- A. Changing her pushing position every 15 minutes.
- B. Notifying the health care provider of her current status.
- C. Continuing with current pushing technique.
- D. Assessing the client's current pain and fetal status.
Correct Answer: D
Rationale: Prolonged pushing (2 hours) in a primigravid client at 42 weeks requires assessment of pain and fetal status to identify potential complications like exhaustion or fetal distress. Changing positions may help but is less urgent, notifying the provider is premature without assessment, and continuing the current technique may not address underlying issues.
You may also like to solve these questions
A post-term neonate diagnosed with persistent pulmonary hypertension is prescribed intravenous tolazoline (Priscoline). While administering this drug, the nurse should monitor the neonate for?
- A. Feeding behaviors.
- B. Temperature.
- C. Skin color.
- D. Blood pressure.
Correct Answer: D
Rationale: Tolazoline is a vasodilator, and monitoring blood pressure is critical due to the risk of hypotension.
A nurse is teaching a client about the lactational amenorrhea method. Which of the following client statements indicates a need for further teaching?
- A. I need to exclusively breastfeed for this method to work.
- B. This method is effective for up to 6 months postpartum.
- C. I can use this method even if my periods have returned.
- D. I must breastfeed on demand, including at night.
Correct Answer: C
Rationale: The lactational amenorrhea method is not effective if periods have returned, as this indicates ovulation may have resumed, requiring further teaching. The other statements are correct.
Assessment of a 15-year-old primigravid client at term in active labor reveals cervical dilation at 7 cm with complete effacement. The nurse should assess the client for which of the following first?
- A. Uterine inversion.
- B. Cephalopelvic disproportion (CPD).
- C. Rapid third stage of labor.
- D. Decreased ability to push.
Correct Answer: B
Rationale: At 7 cm dilation in active labor, assessing for cephalopelvic disproportion is critical, as it can impede labor progression and may require intervention. Uterine inversion and rapid third stage occur post-delivery, and decreased pushing ability is relevant only in the second stage.
A nurse is discussing the contraceptive ring with a client. Which of the following client statements indicates understanding?
- A. I can remove the ring for up to 3 hours if needed.
- B. The ring is replaced every week.
- C. The ring requires daily insertion.
- D. The ring provides long-term contraception for 5 years.
Correct Answer: A
Rationale: The vaginal contraceptive ring can be removed for up to 3 hours if needed without losing effectiveness. It is replaced every 3 weeks (not weekly), not inserted daily, and provides contraception for one cycle, not 5 years.
The nurse is completing discharge instructions with a new mother and is concerned about her safety. Which statement by the client indicates the client needs further instructions?
- A. I will need to be checked out by the doctor in a week.
- B. I need to wear a sports bra for a few days so I don't get milk.
- C. I can get pregnant now if I don't use birth control.
- D. I may feel sad for a few days but should be OK within a few days.
Correct Answer: B
Rationale: Wearing a sports bra does not prevent milk production; this statement indicates a misunderstanding of lactation suppression.