Nokea
The nurse is teaching a client and her partner about the technique of counter pressure during labor. Which of the following statements by the nurse is appropriate?
- A. Your partner will apply upward pressure on your lower abdomen between contractions
- B. Your partner will apply continuous firm pressure between your thumb and index finger
- C. Your partner will apply pressure to the top of your uterus during contractions
- D. Your partner will apply steady pressure with a tennis ball to your lower back
Correct Answer: D
Rationale: The correct answer is D because counter pressure is typically applied to the lower back to help alleviate back pain during labor contractions. This technique can help relieve discomfort by stimulating pressure receptors and distracting from the pain of contractions. Choice A is incorrect as upward pressure on the lower abdomen is not the standard technique for counter pressure. Choice B is incorrect as applying pressure between the thumb and index finger is not relevant to counter pressure. Choice C is incorrect as pressure should be applied to the lower back, not the top of the uterus, during contractions.
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A nurse is caring for a client who is in the second stage of labor. Which of the following manifestations should the nurse expect?
- A. The client expels the placenta
- B. The client experiences gradual dilation of the cervix
- C. The client begins have regular contractions.
- D. The client delivers the newborn
Correct Answer: D
Rationale: The correct answer is D. In the second stage of labor, the client delivers the newborn. This stage begins with full dilation of the cervix and ends with the birth of the baby. The expulsion of the placenta (Choice A) occurs in the third stage of labor. Gradual dilation of the cervix (Choice B) is characteristic of the first stage of labor. Regular contractions (Choice C) may occur throughout labor but are not specific to the second stage. So, the correct answer is D because it aligns with the chronological progression of labor stages.
A nurse is planning care for a newborn who is scheduled to start phototherapy using a lamp. Which of the following actions should the nurse include in the plan?
- A. Apply a thin layer of lotion to the newborn skin every 8 hrs.
- B. Give the newborn 1oz of glucose water every 4 hrs
- C. Ensure the newborn eyes are closed beneath the shield.
- D. Dress the newborn in a thin layer of clothing during therapy
Correct Answer: C
Rationale: Rationale: Choice C is correct because ensuring the newborn's eyes are closed beneath the shield during phototherapy prevents potential eye damage from the bright light. Closing the eyes protects the delicate eye tissues from exposure to the intense light. This action is crucial in preventing eye injury and promoting the safety and well-being of the newborn.
Incorrect Choices:
A: Applying lotion to the skin can intensify the effects of the light and should be avoided.
B: Giving glucose water is unnecessary and not related to phototherapy.
D: Dressing the newborn in clothing can interfere with the effectiveness of the light therapy.
A nurse on the labor and delivery unit is assessing four clients. Which of the following clients is a candidate for an induction of labor with misoprostol?
- A. A client who has active genital herpes
- B. A client who has gestational diabetes mellitus
- C. A client who has a previous uterine incision
- D. A client who has placenta previa
Correct Answer: B
Rationale: The correct answer is B: A client who has gestational diabetes mellitus. Induction of labor with misoprostol is safe for clients with gestational diabetes mellitus as it does not affect blood glucose levels. Misoprostol is contraindicated in clients with active genital herpes (Choice A) due to risk of viral transmission. It is also contraindicated in clients with a previous uterine incision (Choice C) as it may increase the risk of uterine rupture. Clients with placenta previa (Choice D) should not undergo induction with misoprostol due to the risk of increasing bleeding.
A nurse is caring for a client who has gestational diabetes mellitus. Which of the following clinical findings should indicate to the nurse the client has hyperglycemia?
- A. Double vision
- B. Increased urination
- C. Sweating
- D. Dizziness
Correct Answer: B
Rationale: The correct answer is B: Increased urination. Hyperglycemia in gestational diabetes mellitus leads to elevated blood glucose levels, causing the kidneys to filter excess glucose into the urine, leading to increased urination (polyuria). This is due to the osmotic effect of glucose drawing water from the body into the urine. Double vision (choice A) is more indicative of neurological issues. Sweating (choice C) can be a response to hypoglycemia rather than hyperglycemia. Dizziness (choice D) can be a symptom of both hyperglycemia and hypoglycemia, but it is not specific to hyperglycemia.
A nurse is planning care immediately following birth for a newborn who has myelomeningocele that is leaking cerebrospinal fluid.
- A. Administer broad-spectrum antibiotics
- B. Cleans the site with povidone-iodine
- C. Monitor the rectal temperature every 4 hours
- D. Prepare for surgical closure after 72 hours
Correct Answer: A
Rationale: The correct answer is A. Administering broad-spectrum antibiotics is crucial to prevent infection since the exposed spinal cord increases the risk. Antibiotics help reduce the risk of meningitis and sepsis. Choice B is incorrect as povidone-iodine can be irritating to the sensitive skin around the defect. Choice C is incorrect as monitoring rectal temperature is not directly related to the immediate care needed for a myelomeningocele. Choice D is incorrect because surgical closure should be done as soon as possible to prevent further complications.