Nokea
The nurse should do which of the following actions first when admitting a multigravid client at 36 weeks' gestation with a probable diagnosis of abruptio placentae?
- A. Prepare the client for a vaginal examination.
- B. Obtain a brief history from the client.
- C. Insert a large-gauge intravenous catheter.
- D. Prepare the client for an ultrasound scan.
Correct Answer: C
Rationale: Establishing IV access is critical in managing abruptio placentae.
You may also like to solve these questions
A primigravid client whose cervix is 7 cm dilated with the fetus at 0 station and in a left occipitoposterior (LOP) position requests pain relief for severe back pain. The nurse should:
- A. Provide firm pressure to the client's sacral area.
- B. Prepare the client for a cesarean delivery.
- C. Prepare the client for a precipitate delivery.
- D. Place the client in a left side-lying position.
Correct Answer: A
Rationale: LOP position often causes severe back pain due to the fetal occiput pressing against the sacrum. Firm sacral pressure (counterpressure) can alleviate this pain. Cesarean or precipitate delivery is not indicated unless other complications arise, and side-lying may help but is less specific.
A primigravid client who has had a prolonged labor but now is completely dilated has received epidural anesthesia. Which of the following should the nurse include in the teaching plan about pushing?
- A. The client needs to push for at least 1 to 3 minutes.
- B. Pushing is most effective when the client holds her breath.
- C. The client should be urged to push with an open glottis.
- D. Pushing is limited to times when she feels the urge.
Correct Answer: C
Rationale: Pushing with an open glottis (exhaling during effort) is effective and reduces the risk of Valsalva maneuver complications. Prolonged pushing (1–3 minutes) is unrealistic, holding breath is discouraged, and with epidurals, the urge to push may be diminished.
A 25-year-old primiparous client who delivered a viable neonate 2 hours ago has decided to breast-feed her neonate. Which of the following instructions should the nurse address as the highest priority in the teaching plan about preventing nipple soreness?
- A. Keeping plastic liners in the brassiere to keep the nipple drier.
- B. Placing as much of the areola as possible into the baby's mouth.
- C. Smoothly pulling the nipple out of the mouth after 10 minutes.
- D. Removing any remaining milk left on the nipple with a soft washcloth.
Correct Answer: B
Rationale: Proper latch with the areola in the baby's mouth prevents nipple soreness by reducing trauma.
A client is considering the cervical cap. Which of the following statements by the nurse is accurate?
- A. The cervical cap can be left in place for up to 72 hours.
- B. The cervical cap does not require spermicide.
- C. The cervical cap requires a prescription and fitting.
- D. The cervical cap is highly effective for women who have given birth.
Correct Answer: C
Rationale: The cervical cap requires a prescription and fitting by a healthcare provider for proper use. It can be left in place for up to 48 hours, requires spermicide, and is less effective for women who have given birth.
The nurse assesses a primiparous client in labor for 20 hours. The nurse identifies late decelerations on the monitor and initiates standard procedures for the labor client with this wave pattern. Which intravenous should the nurse perform? Select all that apply.
- A. Administering oxygen via mask to the client.
- B. Questioning the client about the effectiveness of pain relief.
- C. Placing the client on her side.
- D. Readjusting the monitor to a more comfortable position.
- E. Applying an internal fetal monitor to help identify the cause of the decelerations.
Correct Answer: A,C
Rationale: Late decelerations indicate uteroplacental insufficiency. Standard interventions include administering oxygen to improve fetal oxygenation and placing the client on her side to enhance uterine perfusion. Questioning pain relief or readjusting the monitor does not address the issue, and internal monitoring may be considered but is not the first step.