Nokea
The nurse is caring for the 30-weeks-pregnant client who is having contractions every 1½ to 2 minutes with spontaneous rupture of membranes 2 hours ago. Her cervix is 8 cm dilated and 100% effaced. The nurse determines that delivery is imminent. What intervention is the most important at this time?
- A. Administering a tocolytic agent
- B. Providing teaching information on premature infant care
- C. Notifying neonatology of the impending birth
- D. Preparing for a cesarean section birth
Correct Answer: C
Rationale: The most important intervention is to notify the neonatal team of the delivery because the team members will be needed for respiratory support and possible resuscitation. Tocolytic agents, such as nifedipine (Procardia), can be used for short-term intervention to slow down contractions and delay birth, but it is too late to administer a tocolytic agent. Teaching is important but is not appropriate at this time. A cesarean birth is indicated if there are other obstetrical needs.
You may also like to solve these questions
Which statement by the client indicates understanding of prenatal education?
- A. I should avoid all exercise during pregnancy.
- B. I need to attend prenatal visits only in the third trimester.
- C. I should report any decrease in fetal movement.
- D. I can consume alcohol in moderation after the first trimester.
Correct Answer: C
Rationale: Reporting decreased fetal movement is critical, as it may indicate fetal distress, showing the client understands key prenatal education.
Immediately after delivery of the client’s placenta, the nurse palpates the client’s uterine fundus. The fundus is firm and located halfway between the umbilicus and symphysis pubis. Which action should the nurse take based on the assessment findings?
- A. Immediately begin to massage the uterus
- B. Document the findings of the fundus
- C. Assess the client for bladder distention
- D. Monitor for increased vaginal bleeding
Correct Answer: B
Rationale: Uterine massage is indicated only if the uterus does not feel firm and contracted. Immediately after birth, the uterus should contract, and the fundus should be located one-half to two-thirds of the way between the symphysis pubis and umbilicus. Thus the only action required is to document the assessment finding. There is no indication that the bladder is full. A full bladder will cause uterine displacement to either side of the abdomen. The uterus is firm; there is no reason to infer that increased vaginal bleeding would occur.
The laboring client is at 5/100/0, RCA, and having difficulty coping with her contractions. She does not want an epidural analgesia or medications. How can the nurse best assist the client and her partner at this time?
- A. Apply counter pressure to sacral area with a firm object.
- B. Implement effleurage (light massage) of the abdomen.
- C. Provide a quiet, calm, and relaxed labor environment.
- D. Re-emphasize modified-paced breathing techniques.
Correct Answer: D
Rationale: Breathing techniques provide distraction, reduce pain perception, and help the client maintain control during labor. The modified-paced breathing technique is usually more effective during active labor (4—7 cm). The client is at 5 cm. The modified-paced technique is performed at about twice the normal breathing rate and requires that the client remain alert and concentrate fully on her breathing. Counter pressure can be helpful to cope with internal pressure sensations and pain in the lower back when the fetus is in posterior position. The fetus is ROA or right occiput anterior position. Effleurage can distract from contraction pain during the latent phase of the first stage of labor. This client is in active labor, and as labor progresses, hyperesthesia occurs, increasing the likelihood that effleurage will be uncomfortable and less effective. Providing a quiet, calm, and relaxed labor environment should be part of the nursing responsibilities to help the client cope with contractions, but this is not the best option.
The nurse advises a client with a history of miscarriage to monitor which symptom?
- A. Mild fatigue
- B. Vaginal spotting
- C. Increased appetite
- D. Normal fetal movement
Correct Answer: B
Rationale: Vaginal spotting may indicate a threatened miscarriage, requiring close monitoring and medical evaluation.
The laboring client just had a convulsion after being given regional anesthesia. Which interventions should the nurse implement? Select all that apply.
- A. Establish an airway.
- B. Position on her right side.
- C. Provide 100% oxygen.
- D. Administer diazepam.
- E. Page the anesthesiologist STAT.
Correct Answer: A,C,D,E
Rationale: The client experiencing a convulsion related to anesthesia should first have an airway established. The client experiencing a convulsion related to anesthesia should receive 100% oxygen so that the mother and fetus remain oxygenated. Small doses of diazepam or thiopental can be administered to stop the convulsions. The anesthesiologist should be STAT paged to provide assistance; the convulsion was initiated by the regional anesthetic. The client’s head should be turned to the side if vomiting occurs, but the client typically remains in a left lateral tilt position so an airway can be maintained. Positioning on the right side can cause aortocaval compression.