Nokea
Mother in labor, nonreassuring fetal heart rate pattern, lying on left side
The nurse notes a nonreassuring pattern of the fetal heart rate. The mother is already lying on her left side. What nursing action is indicated?
- A. Change her position to the right side.
- B. Place a wedge under the left hip.
- C. Lower the head of the bed.
- D. Place the mother in a Trendelenburg position.
Correct Answer: B
Rationale: Placing a wedge under the left hip is a common intervention to improve uteroplacental blood flow by tilting the uterus off the vena cava, enhancing venous return and cardiac output, which can positively affect fetal oxygenation.
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Client at 40 weeks gestation, active labor, 6 cm cervical dilation, 100% effacement, blood pressure 82/52 mm Hg
A nurse is caring for a client who is at 40 weeks gestation and is in active labor. The client has 6 cm of cervical dilation and 100% cervical effacement. The nurse obtains the client's blood pressure reading as 82/52 mm Hg. Which of the following nursing interventions should the nurse perform?
- A. Assist the client to turn onto her side.
- B. Prepare for an immediate vaginal delivery.
- C. Prepare for a cesarean birth.
- D. Assist the client to an upright position.
Correct Answer: A
Rationale: Assisting the client to turn onto her side can improve blood flow to the placenta and increase fetal oxygenation, addressing hypotension which is a common cause of decreased uteroplacental perfusion.
Woman gave birth vaginally to a 9-pound, 12-ounce girl yesterday, orders for perineal ice packs, sitz bath, stool softener
A woman gave birth vaginally to a 9-pound, 12-ounce girl yesterday. Her primary health care provider has written orders for perineal ice packs, use of a sitz bath tid, and a stool softener. What information is most closely correlated with these orders?
- A. The woman had a vacuum-assisted birth.
- B. The woman is a gravida 2, para 2.
- C. The woman has an episiotomy.
- D. The woman received epidural anesthesia.
Correct Answer: C
Rationale: An episiotomy correlates with orders for ice packs, sitz baths, and stool softeners, as these address pain and healing of the perineal incision.
2-day-old newborn
The nurse explains to the parents of a 2-day-old newborn that decreased life span of neonatal red blood cells has contributed to which complication?
- A. Hyperbilirubinemia.
- B. Respiratory distress syndrome.
- C. Polycythemia.
- D. Transient tachypnea.
Correct Answer: A
Rationale: The increased breakdown of neonatal red blood cells, which have a shorter lifespan, produces bilirubin, leading to hyperbilirubinemia and potential jaundice.
Client considered for amniotomy
The nurse understands which condition is a contraindication for an amniotomy.
- A. Right occiput posterior position.
- B. -2 station.
- C. Cephalic presentation.
- D. Dilation less than 3 cm.
Correct Answer: D
Rationale: Dilation less than 3 cm is a contraindication for amniotomy due to increased risks of infection and cord compression.
Client 2 hours postpartum, vaginal birth
A nurse is caring for a client who is 2 hours postpartum following a vaginal birth. Which of the following findings indicates the client's bladder is distended?
- A. Client report of frequent uterine contractions.
- B. Fundus palpable to right of midline.
- C. Less than 2.5 cm of rubra lochia on perineal pad.
- D. Client report of increased thirst.
Correct Answer: B
Rationale: A fundus palpable to the right of midline suggests a distended bladder, which can displace the uterus from its normal position.