Nokea
The physician has ordered prostaglandin gel to be administered vaginally to a newly admitted primigravid client. Which of the following indicate that the client has had a therapeutic response to the medication?
- A. Resting period of 2 minutes between contractions.
- B. Normal patellar and elbow reflexes for the past 2 hours.
- C. Softening of the cervix and beginning effacement.
- D. Leaking of clear amniotic fluid in small amounts.
Correct Answer: C
Rationale: Prostaglandin gel is used for cervical ripening. A therapeutic response is indicated by cervical softening and effacement, preparing the cervix for labor. Resting periods and reflexes are unrelated to the gel's purpose, and leaking amniotic fluid suggests rupture of membranes, not a direct effect of the gel.
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A newly delivered client is asking to go to the bathroom 45 minutes after delivery. She had an epidural for labor & delivery, has an IV infusing, and every 15 minutes assessments are in progress. To provide the safest care for this client the nurse should:
- A. Ask her to remain in bed until the 15-minute assessments are complete.
- B. Assess client's ability to stand and bear weight before going to the bathroom.
- C. Encourage the client to sit at the side of the bed before ambulating to the bathroom.
- D. Ask the client to ambulate the first time with a staff member at her side.
Correct Answer: B
Rationale: Post-epidural, assessing the client's ability to stand and bear weight ensures safety due to potential residual numbness or weakness. Remaining in bed delays care, sitting first is insufficient, and ambulating with assistance assumes mobility not yet confirmed.
The labor and delivery nurse is assigned to triage for the day. There are four clients already in rooms and the following reports have been received about each of these clients. To provide the safest care and best manage time, the nurse should plan to see which client first?
- A. A primipara in active labor at 5 cm asking to be admitted and wanting an epidural.
- B. A primipara who is 100% effaced, 8 cm dilated, and ready to push.
- C. A multipara who thinks her water broke 2 hours ago.
- D. A multipara with contractions every 5 minutes who is 3 cm dilated.
Correct Answer: B
Rationale: A primipara at 8 cm, 100% effaced, and ready to push is in the second stage of labor, requiring immediate attention to prepare for delivery. Other clients are in earlier stages or need assessment but are less urgent.
A nurse is discussing emergency contraception with a client. Which of the following statements by the nurse is accurate?
- A. Emergency contraception is most effective when taken within 72 hours of unprotected intercourse.
- B. Emergency contraception requires a prescription for all women.
- C. Emergency contraception is 100% effective in preventing pregnancy.
- D. Emergency contraception can be used as a regular method of birth control.
Correct Answer: A
Rationale: Emergency contraception, like Plan B, is most effective within 72 hours of unprotected intercourse. It is available over-the-counter for those 17 and older, is not 100% effective, and is not suitable for regular use due to lower efficacy and side effects.
A multigravid client is admitted to the labor area from the emergency room. At the time of admission, the fetal head is crowning, and the client yells, 'The baby's coming!' To help the client remain calm and cooperative during the imminent delivery, which of the following responses by the nurse is most appropriate?
- A. You're right, the baby is coming, so just relax.'
- B. Please don't push because you'll tear your cervix.'
- C. Your doctor will be here as soon as possible.'
- D. I'll explain what's happening to guide you as we go along.'
Correct Answer: D
Rationale: Explaining the process and guiding the client during a precipitous delivery promotes cooperation and reduces anxiety. Telling her to relax is unhelpful, warning against pushing is inaccurate (cervix is fully dilated), and focusing on the doctor's arrival is irrelevant.
During a shift change, the nurse is assigned a new postpartum client who delivered 6 hours ago. Which task should the nurse prioritize?
- A. Perform a fundal assessment.
- B. Educate the client on newborn care.
- C. Assist with breastfeeding initiation.
- D. Administer a prescribed stool softener.
Correct Answer: A
Rationale: Fundal assessment is critical within the first 24 hours to detect complications like hemorrhage.