Nokea
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.
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Woman receiving oxytocin (Pitocin) infusion
For which patient should the oxytocin (Pitocin) infusion be discontinued immediately?
- A. A woman in early labor with contractions every 5 minutes lasting 40 seconds each.
- B. A woman in active labor with contractions every 30 minutes lasting 60 seconds each.
- C. A woman in active labor with contractions every 2 to 3 minutes lasting 70 to 80 seconds each.
- D. A woman in transition with contractions every 1.5 minutes lasting 95 seconds each.
Correct Answer: D
Rationale: Contractions every 1.5 minutes lasting 95 seconds in transition indicate hyperstimulation, risking fetal distress, so the infusion should be stopped.
Client in active labor, 7 cm cervical dilation, 100% effacement, fetus at 1+ station, amniotic membranes intact, sudden urge to push
A nurse is caring for a client who is in active labor with 7 cm of cervical dilation and 100% effacement. The fetus is at 1+ station, and the client's amniotic membranes are intact. The client suddenly states that she needs to push. Which of the following actions should the nurse take?
- A. Assist the client into a comfortable position.
- B. Observe the perineum for signs of crowning.
- C. Have the client pant during the next contractions.
- D. Help the client to the bathroom to void.
- E. None
- F. None
Correct Answer: C
Rationale: Encouraging the client to pant during contractions helps reduce the urge to push when not fully dilated, preventing complications like cervical swelling or tearing.
Newborn born at 37 weeks, 12 hours old, tachypnea, grunting, nasal flaring, substernal retractions, acrocyanosis
Complete the diagram by dragging from the choices below to specify what condition the newborn is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the newborn's progress.
- A. Initiate phototherapy as prescribed.
- B. Obtain a urine drug screen.
- C. Administer Surfactant as prescribed.
- D. Administer 30 mL of oral glucose water.
- E. Provide Oxygen Therapy as needed
- F. Hypoglycemia.
- G. Respiratory distress syndrome.
Correct Answer: B
Rationale: Respiratory distress syndrome is likely due to respiratory symptoms. Administer surfactant and provide oxygen therapy address lung immaturity and oxygenation. Monitor arterial blood gases and oxygen saturation to assess progress.
Newborn, preventing heat loss
To prevent heat loss from convection in a newborn, which action by the nurse is best?
- A. Dry the baby after a bath.
- B. Wrap the baby in warmed blankets.
- C. Place the baby in a warmer.
- D. Move infant away from blowing fan.
Correct Answer: D
Rationale: Moving the infant away from a blowing fan directly prevents heat loss due to air movement, which is a key factor in convection.
Woman received epidural or intrathecal opioids
The main nursing observations of the woman who receives epidural or intrathecal opioids are for all except
- A. delayed respiratory depression.
- B. inability to move lower extremities.
- C. pruritus.
- D. nausea and vomiting.
Correct Answer: A
Rationale: Delayed respiratory depression is not a primary concern with epidural or intrathecal opioids, which have limited systemic effects compared to systemic opioids.