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.
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The nurse identifies which factor as contributing to the client's stress?
- A. Stable employment
- B. Supportive partner
- C. Financial concerns
- D. Regular prenatal visits
Correct Answer: C
Rationale: Financial concerns are a common stressor during pregnancy, impacting the client's psychosocial well-being.
The nurse asks the 12-hour postpartum client, who is breastfeeding her baby now, why she has not yet received a dinner tray. The client states that her mother is bringing curry and that she won’t be eating the hospital food tonight. Which response by the nurse is best?
- A. “Please let me know if you change your mind. I can order food for you later.”
- B. “Since you are breastfeeding, you should avoid eating highly spiced food.”
- C. “I will ask the dietitian to meet with you so you can discuss your nutritional needs.”
- D. “You should not be eating highly spiced food 12 hours after delivery.”
Correct Answer: A
Rationale: Offering to order food later if the client changes her mind is the best response. Many clients have culturally based beliefs about food and beverages that should be consumed in the postpartum period. Unless contraindicated, nurses should support and encourage women to incorporate food preferences with cultural significance into their postpartum diet. Some breastfeeding infants are sensitive to certain flavors, seasonings, or foods, but, there is no evidence to support maternal food restrictions unless the infant shows a sensitivity. If there is a strong family history of a food allergy that causes anaphylaxis, such as a peanut allergy, these foods may be avoided. Many women would benefit from speaking to a dietician, but this client is not at any increased risk that would make a dietary consultation necessary. There are no food restrictions 12 hours after delivery unless there have been complications.
The client tells the nurse, “Most days, I am so happy I am pregnant, but other days, I am not sure that I am ready to have a baby.” Which is the most accurate response from the nurse?
- A. “This is such a happy time in your life. You need to be optimistic to feel happy.”
- B. “How does your spouse feel about the pregnancy? I hope he is happy about the baby.”
- C. “Feeling differently from day to day is normal. How do you feel today?”
- D. “Why do you feel this way? Is there something I can do to make it better for you?”
Correct Answer: C
Rationale: It is most therapeutic to acknowledge the client’s feelings and probe for more information on her thoughts and feelings about the pregnancy. Not all clients consider pregnancy a happy time in their lives, and the nurse should never tell the client how to feel. The nurse should not divert the client’s concerns away from self by bringing up the father’s adaptation to the pregnancy, even though paternal adaptation is related to maternal adaptation. The client may not be able to identify why she has the feelings she is experiencing or how the nurse can make her feel better. This response does not provide an avenue for further exploration of the client’s concerns.
The client, who is 20 days postpartum, telephones the perinatal clinic to tell the nurse that she is having heavy, bright red bleeding since hospital discharge 18 days ago. Which instruction to the client is correct?
- A. “You need to come to the clinic immediately.”
- B. “Decrease physical activity until the bleeding stops.”
- C. “There is no need for concern; this is expected after birth.”
- D. “Call next week if the bleeding has not stopped by then.”
Correct Answer: A
Rationale: Lochia rubra that persists for longer than 2 weeks is suggestive of subinvolution of the uterus, which is the most common cause of delayed postpartum hemorrhage. The client should be seen in the clinic immediately to determine what is causing her abnormal lochial discharge. Increased physical activity can lead to increased lochial discharge, but the client is reporting continuous lochia rubra, which is abnormal. Lochia rubra is expected to last for up to 3 days after birth, not 20 days. Waiting until next week to be seen only delays determining the cause for her abnormal bleeding and increases the risk of the client for other complications.
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.