Nokea
The nurse is caring for the client with a grade 3 placental abruption. Prioritize the prescribed interventions that the nurse should implement.
- A. Obtain serum blood draw for clotting disorders
- B. Administer 1 unit whole blood
- C. Start oxygen at 2—4 liters per nasal cannula
- D. Administer lactated Ringer’s at 200 mL/hr
- E. Prepare for cesarean delivery if fetal distress
- F. Continuous external fetal monitoring
Correct Answer: C,D,F,A,B,E
Rationale: Start oxygen at 2—4 liters per nasal cannula is priority to maximize fetal oxygenation. Administer lactated Ringer’s at 200 mL/hr to treat hypovolemia, increase blood flow, and maximize oxygenation. Continuous external fetal monitoring should be performed to identify fetal distress early. Obtain serum blood draw for clotting disorders, specifically DIC. Administer 1 unit whole blood is next and will depend on the amount of blood loss. Prepare for cesarean delivery if fetal distress would be last because it would depend on the client and fetal status.
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The nurse explains that true labor contractions are characterized by which feature?
- A. Irregular timing
- B. Increasing intensity and frequency
- C. Relief with walking
- D. Occurrence only at night
Correct Answer: B
Rationale: True labor contractions increase in intensity and frequency, distinguishing them from false labor.
The nurse recognizes which symptom as a warning sign of preterm labor?
- A. Mild lower back pain
- B. Regular contractions before 37 weeks
- C. Increased appetite
- D. Frequent urination
Correct Answer: B
Rationale: Regular contractions before 37 weeks are a key sign of preterm labor, requiring immediate medical attention.
The laboring client tells the nurse that she wants to avoid an episiotomy if possible. Which response by the nurse is best?
- A. “Usually making an episiotomy incision is avoided whenever possible.”
- B. “Having an episiotomy reduces prolonged pushing and perineal trauma.”
- C. “An episiotomy is routine because it can prevent pelvic floor damage.”
- D. “Tell me more about your concerns about having an episiotomy.”
Correct Answer: A
Rationale: This statement is best. An episiotomy may be used in some circumstances but is usually avoided if possible. Use of episiotomy increases (not reduces) perineal trauma and increases healing time. Use of episiotomy is not routine, does not decrease pelvic floor damage, and may increase the severity of the trauma. Having the client tell the nurse more about her concerns regarding episiotomy is unnecessary and avoids responding to the client’s comment.
The nurse is teaching the postpartum client, who is breastfeeding, about returning to sexual activity after vaginal delivery. Which statement should the nurse include?
- A. “Orgasm may decrease the amount of breast milk you produce.”
- B. “You may need to use lubrication when resuming sexual intercourse.”
- C. “You should not have sexual intercourse until two months postpartum.”
- D. “Your HCP will let you know when you can resume sexual activity.”
Correct Answer: B
Rationale: Oxytocin is released when the client has an orgasm and may cause breast milk to leak or squirt from the breasts. The production of breast milk may increase, not decrease. The nurse should inform the client that she may need lubrication with sexual intercourse because the low estrogen levels in the early postpartum period causes vaginal dryness. Women should refrain from sexual intercourse until lochia has ceased, which usually takes about 3 weeks. There is no need to wait two months if the lochia has ceased. The client’s HCP does not need to give approval to return to sexual activity.
The nurse correctly informs the participants that women who smoke during pregnancy have a greater risk of which problem?
- A. Having a premature delivery
- B. Having a cesarean birth
- C. Having a large, overweight baby
- D. Developing a prenatal infection
Correct Answer: A
Rationale: Smoking during pregnancy increases the risk of premature delivery due to reduced oxygen and nutrient delivery to the fetus.