Nokea
The physician orders an amnioinfusion for a primigravid client at term who is diagnosed with oligohydramnios. Which of the following should the nurse include in the client's teaching plan about the purpose of this procedure?
- A. To decrease the frequency and severity of variable decelerations.
- B. To minimize the possibility of fetal metabolic alkalosis.
- C. To increase the fetal heart rate accelerations during a contraction.
- D. To raise the amniotic fluid index to more than 15 cm.
Correct Answer: A
Rationale: Amnioinfusion replaces amniotic fluid in oligohydramnios, reducing cord compression and the frequency/severity of variable decelerations. It does not affect metabolic alkalosis, heart rate accelerations, or guarantee a specific fluid index.
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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.
The nurse in a postpartum couplet room is making rounds prior to ending the shift. Which of the following indicate that the safety needs of the clients have been met?
- A. Infant lying on abdomen.
- B. Security tags in place.
- C. Identification system on mother and infant.
- D. Bulb syringe within sight.
- E. Someone in room able to care for infant.
- F. Infant in the mother's bed, side rails up.
- G. Infant in the mother's arms, both asleep.
Correct Answer: B,C,D,E
Rationale: Safety needs are met with security tags, identification systems, a bulb syringe for suctioning, and someone present to care for the infant.
A laboring client smiles pleasantly at the nurse when asked simple questions. The client speaks no English and the interpreter is busy with an emergency situation. At her last vaginal examination, the client was 5 cm dilated, 100% effaced, and at 0 station. While working with this client, which of the following responses indicates that the client may be approaching delivery?
- A. The fetal monitor strip shows late decelerations.
- B. The client begins to speak to her family in her native language.
- C. The fetal monitor strip shows early decelerations.
- D. The client's facial expressions become animated.
Correct Answer: D
Rationale: Animated facial expressions (e.g., grimacing, distress) may indicate transition or second-stage labor, suggesting imminent delivery. Late decelerations indicate fetal distress, speaking to family is nonspecific, and early decelerations are normal.
The nurse is evaluating the client who delivered vaginally 2 hours ago and is experiencing postpartum pain rated 8 on scale of 1 to 10. The client is a G 4, P 4, breast-feeding mother who would like medication to decrease the pain in her uterus. Which of the medications listed on the orders sheet would be the most appropriate for this client?
- A. Aspirin 1,000 mg P.O. q 4 to 6 hour p.r.n.
- B. Ibuprofen 800 mg P.O. q 6 to 8 hour p.r.n.
- C. Colace 100 mg P.O. b.i.d.
- D. Vicodin 1 to 2 tabs P.O. q 4 to 6 hour p.r.n.
Correct Answer: B
Rationale: Ibuprofen is safe for breastfeeding mothers and effective for uterine cramping pain, unlike aspirin (risk of bleeding), Colace (stool softener), or Vicodin (opioid, less preferred due to sedation risks).
A client asks about the disadvantages of oral contraceptives. Which of the following would the nurse include?
- A. They must be taken at the same time daily for maximum effectiveness.
- B. They provide long-term contraception for up to 5 years.
- C. They are highly effective without side effects.
- D. They protect against STIs.
Correct Answer: A
Rationale: Oral contraceptives must be taken at the same time daily for maximum effectiveness, as timing affects hormone levels. They are short-term (daily), have potential side effects, and do not protect against STIs.