Nokea
The physician orders an amniocentesis for a primigravid client at 35 weeks' gestation in early labor to determine fetal lung maturity. Which of the following is an indicator of fetal lung maturity?
- A. A amount of bilirubin present.
- B. Presence of red blood cells.
- C. Barr body determination.
- D. Lecithin-sphingomyelin (L/S ratio).
Correct Answer: D
Rationale: The lecithin-sphingomyelin (L/S) ratio in amniotic fluid is a key indicator of fetal lung maturity, with a ratio of 2:1 or higher indicating mature lungs. Bilirubin, red blood cells, and Barr body determination are not used for this purpose.
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A multigravid client is admitted to the hospital with a diagnosis of ectopic pregnancy. The nurse anticipates that, because the client's fallopian tube has not yet ruptured, which of the following may be ordered?
- A. Progestin contraceptives(Hylutin).
- B. Medroxyprogesterone(Depo-Provera).
- C. Methotrexate.
- D. Dyphylline(Dilor).
Correct Answer: C
Rationale: Methotrexate is used to treat unruptured ectopic pregnancies.
The nurse is caring for a multigravid client who speaks little English. As the nurse enters the client's room, the nurse observes the client panting on the bed and the fetal head crowning. After calling for assistance and helping the client lie down, which of the following actions should the nurse do next?
- A. Tell the client to push between contractions.
- B. Provide gentle support to the fetal head.
- C. Apply gentle upward traction on the neonate's anterior shoulder.
- D. Massage the perineum to stretch the perineal tissues.
Correct Answer: B
Rationale: With the fetal head crowning, providing gentle support prevents rapid expulsion and perineal trauma. Pushing between contractions is incorrect, traction is for shoulder dystocia, and perineal massage is less urgent.
A nurse and a nursing assistant are caring for clients in a labor and delivery unit. Which task should the registered nurse assign to the nursing assistant?
- A. Perform a fundal check on a 2-day postpartum client.
- B. Remove a fetal monitor and assist a client to the bathroom.
- C. Give ibuprofen 800 mg by mouth to a newly delivered client.
- D. Teach a new mother how to bottle-feed her infant.
Correct Answer: B
Rationale: A nursing assistant can assist with mobility tasks like removing a fetal monitor and helping a client to the bathroom. Fundal checks, medication administration, and teaching require RN skills.
While the nurse is caring for a multiparous client in active labor at 36 weeks' gestation, the client tells the nurse, 'I think my water just broke.' Which of the following should the nurse do first?
- A. Turn the client to the right side.
- B. Assess the color, amount, and odor of the fluid.
- C. Assess the fetal heart rate pattern.
- D. Check the client's cervical dilation.
Correct Answer: C
Rationale: Rupture of membranes can affect fetal well-being, particularly in preterm labor (36 weeks). Assessing the fetal heart rate pattern first ensures the fetus is not in distress (e.g., due to cord compression). Fluid characteristics and dilation are assessed next.
A multigravid client is admitted at 4-cm dilation and requesting pain medication. The nurse gives the client Nubain 15 mg and Phenergan 25 mg slow I.V. push. Within 5 minutes, the client tells the nurse she feels like she needs to have a bowel movement. The nurse should first:
- A. Have naloxone hydrochloride (Narcan) available in the delivery room.
- B. Perform a vaginal examination to determine dilation, effacement, and station.
- C. Prepare for delivery.
- D. Document the client's relief due to pain medication.
Correct Answer: B
Rationale: A sudden urge to have a bowel movement in labor often indicates rapid progression to full dilation or fetal descent. A vaginal examination confirms dilation and station to guide next steps (e.g., preparing for delivery). Naloxone, preparation, or documentation are premature without assessment.