Nokea
The nurse is managing care of a primigravida at full term who is in active labor. What should be included in developing the plan of care for this client?
- A. Oxygen saturation monitoring every half hour.
- B. Supine positioning on back, if it is comfortable.
- C. Anesthesia/pain level assessment every 30 minutes.
- D. Vaginal bleeding, ROM assessment every shift.
Correct Answer: C
Rationale: Regular assessment of anesthesia/pain levels is critical to ensure the client's comfort and to adjust pain management strategies as labor progresses. Oxygen saturation monitoring is not typically required every half hour unless specific complications arise. Supine positioning can cause supine hypotensive syndrome and is generally avoided. Vaginal bleeding and rupture of membranes (ROM) assessments are important but typically performed more frequently than every shift during active labor.
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After the physician explains the prognosis and medical management for atrial septal defect to a primiparous client whose 2-day-old female neonate was diagnosed with this condition, the nurse determines that the mother needs further instructions when she says which of the following?
- A. As my child grows, she may have increased fatigue and difficulty breathing.'
- B. My child may need to have antibiotics if she develops an infection.'
- C. This condition occurs more commonly in females than in males.'
- D. About half of the children born with this defect heal spontaneously.'
Correct Answer: C
Rationale: Atrial septal defects are not significantly more common in females, indicating a need for further instruction.
The nurse is caring for a primipara in active labor when the fetus develops severe bradycardia with late decelerations, and an emergency cesarean delivery is performed with the client under general anesthesia. After the delivery, the client tells the nurse, 'I feel terrible. This is exactly what I didn't want to happen!' Which of the following is a priority nursing diagnosis for this client?
- A. Interrupted family processes related to cesarean delivery.
- B. Anxiety related to incisional scar and neonatal outcome.
- C. Pain related to surgical incision and uterine cramping.
- D. Situational low self-esteem related to inability to deliver vaginally.
Correct Answer: D
Rationale: The client's statement reflects disappointment and possible feelings of failure due to the unplanned cesarean, making situational low self-esteem the priority. Pain, anxiety, and family processes are secondary concerns post-delivery.
In which of the following maternal locations would the nurse place the ultrasound transducer of the external electronic fetal heart rate monitor if a fetus at 34 weeks' gestation is in the left occipitoanterior(LOA) position?
- A. Near the symphysis pubis.
- B. Two inches above the umbilicus.
- C. Below the umbilicus on the left side.
- D. At the level of the umbilicus.
Correct Answer: C
Rationale: The transducer should be placed below the umbilicus on the left side for LOA position.
A client has obtained Plan B (levonorgestrel 0.75 mg, 2 tablets) as emergency contraception. After unprotected intercourse, the client calls the clinic to ask questions about taking the contraceptives. The nurse realizes the client needs further explanation when she makes which of the following responses?
- A. I can wait 3 to 4 days after intercourse to start taking these to prevent pregnancy.
- B. My boyfriend can buy Plan B from the pharmacy if he is over 18 years old.
- C. The birth control works by preventing ovulation or fertilization of the egg.
- D. I can be discussed and have breast tenderness or a headache after using the contraceptive.
Correct Answer: A
Rationale: Plan B is most effective when taken within 72 hours of unprotected intercourse, ideally as soon as possible. Waiting 3 to 4 days reduces its efficacy, indicating a need for further explanation.
After administering hydralazine(Apresoline) 5 mg intravenously as ordered for a primigravid client with severe preeclampsia at 39 weeks' gestation, the nurse should assess the client for:
- A. Tachycardia.
- B. Bradypnea.
- C. Polyuria.
- D. Dysphagia.
Correct Answer: A
Rationale: Tachycardia is a potential side effect of hydralazine.