Nokea
The physician determines that outlet forceps are needed to assist in the delivery of a primigravid client in active labor with a large-for-gestational-size fetus. The nurse reinforces the physician's explanation for using forceps based on the understanding about which of the following concerning the location of the fetus?
- A. Fetal head at the pelvic outlet.
- B. Fetal head at the ischial spines.
- C. Fetal head above the pelvic brim.
- D. Fetal head in the false pelvis.
Correct Answer: A
Rationale: Outlet forceps are used when the fetal head is at the pelvic outlet, visible at the perineum, allowing safe assisted delivery. Higher fetal positions require different interventions.
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Which of the following best identifies the reason for assessing a neonate weighing 1,500 g at 32 weeks' gestation for retinopathy of prematurity (ROP)?
- A. The neonate is at risk because of multiple factors.
- B. Oxygen is being administered at a level of $21%.
- C. The neonate was alkalotic immediately after birth.
- D. Phototherapy is likely to be ordered by the pediatrician.
Correct Answer: A
Rationale: Preterm neonates, especially those with low birth weight and receiving oxygen, are at risk for ROP due to immature retinal development.
A 31-year-old multigravid client at 39 weeks' gestation admitted to the hospital in active labor is receiving intravenous lactated Ringer's solution and a continuous epidural anesthetic. During the first hour after administration of the anesthetic, the nurse should monitor the client for:
- A. Hypotension.
- B. Diaphoresis.
- C. Headache.
- D. Tremors.
Correct Answer: A
Rationale: Epidural anesthesia can cause sympathetic blockade, leading to hypotension, especially within the first hour. Monitoring blood pressure is critical. Diaphoresis, headache, or tremors are less common or less urgent.
Two hours ago, a neonate at 38 weeks' gestation and weighing 3,175 g (7 lb) was born to a primiparous client who tested positive for beta-hemolytic Streptococcus. Which of the following would alert the nurse to notify the pediatrician?
- A. Alkalosis.
- B. Increased muscle tone.
- C. Temperature instability.
- D. Positive Babinski's reflex.
Correct Answer: C
Rationale: Temperature instability can indicate early sepsis, especially in a neonate at risk due to maternal beta-hemolytic Streptococcus.
Four days after a vaginal delivery, the client visits the clinic complaining of excessive lochia rubra with clots. The physician orders methylergonovine maleate (Methergine), 0.2 mg intramuscularly. Before administering this drug, the nurse should assess:
- A. Blood pressure.
- B. Pulse rate.
- C. Breath sounds.
- D. Bowel sounds.
Correct Answer: A
Rationale: Methylergonovine can cause hypertension, so blood pressure assessment is essential before administration.
A neonate delivered at 30 weeks' gestation and weighing $2,000 \mathrm{~g}$ is admitted to the neonatal intensive care unit. What nursing measure will decrease insensible water loss in a neonate?
- A. Bathing the baby as soon after birth as possible.
- B. Use of eye patches with phototherapy.
- C. Use of humidity in the incubator.
- D. Use of a radiant warmer.
Correct Answer: C
Rationale: Using humidity in the incubator helps maintain a moist environment, reducing insensible water loss through the skin, which is critical for preterm neonates with immature skin barriers.