Nokea
The nurse is receiving reports about four pregnant women in active labor who have been admitted to the labor and delivery unit. Which of the following women should the nurse see FIRST?
- A. A 27-year-old nullipara at 38-weeks gestation, has a cervical dilatation of $2 \mathrm{~cm}$, fetus in transverse lie with baseline FHT of $155 \mathrm{bpm}$.
- B. A 32-year-old multipara at term, cervical dilatation of $8 \mathrm{~cm}$, fetus in a vertex presentation with the presenting part at +2 station.
- C. A 22-year-old nullipara at term, cervical dilatation of $10 \mathrm{~cm}, 100 \%$ effaced, fetus presenting as left occiput posterior with short-term variability of the FHT at 3-5 beats.
- D. A 34-year-old multipara at 37-weeks gestation, has intact amniotic membranes, cervical dilatation of $3 \mathrm{~cm}$, and fetus in a frank breech presentation with the presenting part at 0 station.
Correct Answer: B
Rationale: The multipara at 8 cm dilatation is in advanced labor and likely to deliver soon, making her the priority. Options A, C, and D are less urgent: transverse lie needs monitoring, nullipara at 10 cm has a longer second stage, and breech at 3 cm is early.
You may also like to solve these questions
The nurse is instructing a client being discharged on tranylcypromine sulfate (Parnate).
The nurse knows further instruction is needed if the client makes which of the following statements?
- A. To celebrate, my wife and I are going out for pepperoni pizza and wine tonight.'
- B. I plan to use sunblock at the beach this summer.'
- C. When I get home, I am going to start a diet so I can lose some weight.'
- D. Now that I feel so much better, I have more energy.'
Correct Answer: A
Rationale: Strategy: Determine how each answer choice relates to Parnate. (1) correct-Parnate is a MAO inhibitor; must avoid food with tyramine (aged cheese, yogurt, beer, wine) to prevent hypertensive crisis (2) sunblock required (3) no contraindication to sensible weight reduction diet (4) expected outcome of antidepressant; takes 3-4 weeks to work
A client who had a lumbar laminectomy has just returned to the nursing care unit following an uneventful stay in the postanesthesia care unit. How should the nurse position the client?
- A. Supine
- B. Prone
- C. Side-lying
- D. Semi-reclining
Correct Answer: C
Rationale: Side-lying with a pillow between legs maintains spinal alignment post-lumbar laminectomy, reducing strain. Supine or prone may stress the surgical site, and semi-reclining is less ideal.
The nurse is caring for a client who is postoperative day 1 after a total hip replacement. Which of the following actions is the PRIORITY?
- A. Encourage the client to use the incentive spirometer.
- B. Administer pain medication as needed.
- C. Position the client with the legs abducted.
- D. Check the surgical dressing for drainage.
Correct Answer: C
Rationale: Positioning with legs abducted prevents hip dislocation, a critical complication post-hip replacement. Options A, B, and D are important but secondary: incentive spirometry prevents pneumonia, pain management supports recovery, and dressing checks monitor bleeding.
A client is scheduled for a myelogram at the outpatient clinic.
Which of the following statements, if made by the nurse, correctly describes a myelogram?
- A. The Test involves x-ray examination of the entire spinal column to determine the extent of myelin breakdown.'
- B. The Test involves injection of a contrast medium into a suspected ruptured vertebral disk, allowing radiographic visualization of the disk.'
- C. The Test involves a lumbar puncture with injection of contrast medium, allowing accettare visualization of the vertebral canal.'
- D. The Test involves x-ray examination of the vertebral column following injection of air into the subarachnoid space.'
Correct Answer: C
Rationale: Strategy: Determine how each answer choice relates to a myelogram. (1) x-ray examination cannot determine the extent of myelin breakdown (2) no such procedure (3) correct-contrast medium or air is injected into spinal subarachnoid space through a spinal puncture, identifies tumors, cysts, herniated vertebral discs (4) no such procedure
A laboring woman who has dystocia is receiving oxytocin. The nurse observes a contraction lasting 90 seconds. What should the nurse do first?
- A. Slow down the rate of the oxytocin
- B. Turn the woman on her left side
- C. Give the woman oxygen
- D. Stop the oxytocin
Correct Answer: D
Rationale: Contractions longer than 60-90 seconds risk fetal hypoxia; stopping oxytocin immediately reduces uterine stimulation, prioritizing fetal safety.