Nokea
The physician orders oxytocin to be added to the intravenous fluids of a 30-year-old multigravid client at 37 weeks' gestation with twins after vaginal delivery. The nurse should administer the oxytocin after delivery of which of the following?
- A. First placenta.
- B. First twin.
- C. Second placenta.
- D. Second twin.
Correct Answer: C
Rationale: Oxytocin is administered post-delivery of both twins and placentas to promote uterine contraction and prevent postpartum hemorrhage. Administering earlier risks complications with the second twin or placentas.
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A primigravid client who has had a prolonged labor but now is completely dilated has received epidural anesthesia. Which of the following should the nurse include in the teaching plan about pushing?
- A. The client needs to push for at least 1 to 3 minutes.
- B. Pushing is most effective when the client holds her breath.
- C. The client should be urged to push with an open glottis.
- D. Pushing is limited to times when she feels the urge.
Correct Answer: C
Rationale: Pushing with an open glottis (exhaling during effort) is effective and reduces the risk of Valsalva maneuver complications. Prolonged pushing (1–3 minutes) is unrealistic, holding breath is discouraged, and with epidurals, the urge to push may be diminished.
A client asks the nurse about the effectiveness of natural family planning methods. Which of the following responses by the nurse is most accurate?
- A. Natural family planning is as effective as oral contraceptives when used correctly.
- B. The effectiveness of natural family planning depends on consistent monitoring and abstinence during fertile periods.
- C. Natural family planning is less effective than barrier methods likeå®çŸ³
- D. Natural family planning requires no special equipment or cost.
Correct Answer: B
Rationale: The effectiveness of natural family planning depends on consistent monitoring and abstinence during fertile periods. It is less effective than oral contraceptives or barrier methods due to variability in ovulation and user adherence.
After teaching the multiparous mother about hemolytic disease of the newborn and Rh sensitization, the nurse determines that the client understands why she was not sensitized during her other pregnancy when she says which of the following?
- A. My other baby had a different father.'
- B. Like most women, I have immunity against the Rh factor.'
- C. Antibodies are not usually formed until after exposure to an antigen.'
- D. My blood couldn't neutralize antibodies formed from my first pregnancy.'
Correct Answer: C
Rationale: Antibodies form after exposure to an Rh-positive fetus, typically not during the first pregnancy, explaining why sensitization did not occur previously.
While the nurse is preparing to assist the primiparous client to the bathroom to void 6 hours after a vaginal delivery under epidural anesthesia, the client says that she feels dizzy when sitting up on the side of the bed. The nurse explains that this is most likely caused by which of the following?
- A. Effects of the anesthetic during labor.
- B. Hemorrhage during the delivery process.
- C. Effects of analgesics used during labor.
- D. Decreased blood volume in the vascular system.
Correct Answer: A
Rationale: Dizziness when sitting up is likely due to residual effects of epidural anesthesia, which can cause orthostatic hypotension.
A client at 28 weeks' gestation in premature labor was placed on ritodrine(Yutopar). To maintain the pregnancy, the physician orders the client to have 10 mg now, 10 mg in 2 hours, and then 20 mg every 4 hours while contractions persist, not to exceed the maximum daily oral dose of 120 mg. At what time will the client have reached the maximum dose if she begins taking the medication at 10:00 a.m. and follows the physician's order?
- A. 10:00 a.m.
- B. 10:00 p.m.
- C. 12:00 a.m.
- D. 2:00 a.m.
Correct Answer: B
Rationale: The client will reach the maximum dose at 10:00 p.m.