Nokea
A nurse is caring for a client who is in the transition phase of labor and reports a pain level of 7 on a scale of 0 to Which of the following actions should the nurse take?
- A. Instruct the client to use effleurage
- B. Apply counter pressure to the client sacral.
- C. Assist the client with patterned-paced breathing.
- D. Teach the client the technique of biofeedback.
Correct Answer: B
Rationale: In the transition phase of labor, the contractions are intense and the client may experience significant discomfort and pain. Applying counter pressure to the client's sacral area can help alleviate this pain by providing some relief and support. Counter pressure involves applying firm pressure with the palms or fists to the lower back or sacral area during contractions. This technique can help to relieve some of the pressure and discomfort experienced during contractions, making it a beneficial action for the nurse to take in this situation.
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A nurse in the labor and delivery unit is caring for a client who is undergoing external fetal monitoring. The nurse observes that the fetal heart rate begins to slow after the start of a contraction and the lowest rate occurs after the peak of the contraction. Which of the following actions should the nurse take first?
- A. Place the client in the lateral position.
- B. Increase the rate of maintenance IV infusion.
- C. Elevate the client's legs.
Correct Answer: A
Rationale: The priority action for a nurse to take when observing a slowing of the fetal heart rate after the start of a contraction, with the lowest rate occurring after the peak of the contraction, is to place the client in the lateral position. This position, specifically the left lateral position, can alleviate pressure on the vena cava, improve blood flow to the placenta, and help optimize fetal oxygenation. By changing the client's position, the nurse can potentially relieve the decelerations seen in the fetal heart rate and promote better oxygenation for the fetus. This intervention is effective and can be quickly implemented in a labor and delivery setting to support fetal well-being.
A nurse on an antepartum unit is reviewing the medical records for four clients. Which of the following clients should the nurse assess first?
- A. A client who has diabetes mellitus and an HbA1c of 5.8%
- B. A client who has preeclampsia and a creatinine level of 1.1 mg/ dL
- C. A client who has hyperemesis gravidarum and a sodium level of 110 mEq/L
- D. A client who has placenta previa and a hematocrit of 36%
Correct Answer: C
Rationale: A client with hyperemesis gravidarum and a sodium level of 110 mEq/L is at risk for severe dehydration and electrolyte imbalance, particularly hyponatremia (low sodium level). Hyponatremia can lead to serious complications such as seizures, coma, and even death if not promptly addressed. Therefore, this client should be assessed first to prevent any potential life-threatening conditions. The nurse should prioritize interventions to address the electrolyte imbalance and dehydration in this client to ensure their safety and well-being.
A pregnant client asks about the purpose of an ultrasound at 20 weeks' gestation. What is the best response?
- A. To confirm pregnancy viability.
- B. To check for genetic abnormalities.
- C. To assess fetal anatomy and growth.
- D. To determine the sex of the baby.
Correct Answer: C
Rationale: The 20-week ultrasound is primarily for assessing fetal anatomy, growth, and development.
A client at 32 weeks' gestation reports regular uterine contractions every 10 minutes. What is the nurse's priority action?
- A. Administer tocolytic medication as prescribed.
- B. Perform a sterile vaginal examination.
- C. Assess for cervical changes and fetal heart rate.
- D. Encourage ambulation to relieve discomfort.
Correct Answer: C
Rationale: Assessing cervical changes and fetal heart rate is essential to determine whether the client is in preterm labor.
What blood test is important for potential blood type incompatibility issues during pregnancy?
- A. complete blood count (CBC)
- B. blood glucose
- C. blood type and Rh factor
- D. blood lipid profile
Correct Answer: C
Rationale: