Nokea
The nurse is working with four clients on the obstetrical unit. Which client will be the highest priority for a cesarean section?
- A. Client at 40 weeks' gestation whose fetus weighs 8 lb by ultrasound estimate.
- B. Client at 37 weeks' gestation with fetus in ROP position.
- C. Client at 32 weeks' gestation with fetus in breech position.
- D. Client at 38 weeks' gestation with active herpes lesions.
Correct Answer: D
Rationale: Active herpes lesions necessitate a cesarean delivery to prevent neonatal transmission.
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A multigravid client is admitted at 4-cm dilation and requesting pain medication. The nurse gives the client Nubain 15 mg and Phenergan 25 mg slow I.V. push. Within 5 minutes, the client tells the nurse she feels like she needs to have a bowel movement. The nurse should first:
- A. Have naloxone hydrochloride (Narcan) available in the delivery room.
- B. Perform a vaginal examination to determine dilation, effacement, and station.
- C. Prepare for delivery.
- D. Document the client's relief due to pain medication.
Correct Answer: B
Rationale: A sudden urge to have a bowel movement in labor often indicates rapid progression to full dilation or fetal descent. A vaginal examination confirms dilation and station to guide next steps (e.g., preparing for delivery). Naloxone, preparation, or documentation are premature without assessment.
An infant born premature at 34 weeks is receiving gavage feedings. The client holding her infant asks why the nurse places a pacifier in the infant's mouth during these feedings. The nurse replies that the pacifier helps in what ways? Select all that apply.
- A. Teaches the infant to suck and swallow.
- B. Provides oral stimulation.
- C. Keeps oral mucus membranes moist while the tube is in place.
- D. Reminds the infant how to suck.
- E. Stimulates secretions that help gastric emptying.
Correct Answer: B,D
Rationale: The pacifier provides oral stimulation and reminds the infant how to suck, promoting oral motor development.
A primiparous client asks how to store breast milk safely at room temperature. The nurse should instruct the client that breast milk can be left at room temperature for up to:
- A. 2 hours.
- B. 4 hours.
- C. 6 hours.
- D. 8 hours.
Correct Answer: C
Rationale: Breast milk is safe at room temperature (up to 77°F) for up to 6 hours, minimizing bacterial growth.
A client is induced with oxytocin (Pitocin). The fetal heart rate is showing accelerations lasting 15 seconds and exceeding the baseline with fetal movement. What action associated with this finding should the nurse take?
- A. Turn the client to her left side.
- B. Administer oxygen via facemask at 10 to 12 L/minute.
- C. Notify the health care provider of the situation.
- D. Document fetal well-being.
Correct Answer: D
Rationale: Fetal heart rate accelerations with movement indicate fetal well-being, requiring no intervention beyond documentation. Repositioning, oxygen, or notification are unnecessary.
While assisting a primiparous client with her first breast-feeding session, which of the following actions should the nurse instruct the mother to do to stimulate the neonate to open the mouth and grasp the nipple?
- A. Pull down gently on the neonate's chin and insert the nipple.
- B. Squeeze both of the neonate's cheeks simultaneously.
- C. Place the nipple into the neonate's mouth on top of the tongue.
- D. Brush the neonate's lips lightly with the nipple.
Correct Answer: D
Rationale: Brushing the neonate's lips with the nipple stimulates the rooting reflex, encouraging the mouth to open.