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The physician who elects to perform a cesarean delivery on a primigravid client for fetal distress has informed the client of possible risks during the procedure. When the nurse asks the client to sign the consent form, the client's husband says, 'I'll sign it for her. She's too upset by what is happening to make this decision.' The nurse should:
- A. Ask the client if this is acceptable to her.
- B. Have the client and her husband both sign the consent form.
- C. Ask the client to sign the consent form.
- D. Ask the doctor to witness the consent form.
Correct Answer: C
Rationale: The client must provide informed consent unless incapacitated. The nurse should ask the client to sign, ensuring she understands despite her distress. The husband cannot sign unless legally authorized, and dual signatures or physician witnessing are unnecessary.
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The nurse assesses a primiparous client in labor for 20 hours. The nurse identifies late decelerations on the monitor and initiates standard procedures for the labor client with this wave pattern. Which intravenous should the nurse perform? Select all that apply.
- A. Administering oxygen via mask to the client.
- B. Questioning the client about the effectiveness of pain relief.
- C. Placing the client on her side.
- D. Readjusting the monitor to a more comfortable position.
- E. Applying an internal fetal monitor to help identify the cause of the decelerations.
Correct Answer: A,C
Rationale: Late decelerations indicate uteroplacental insufficiency. Standard interventions include administering oxygen to improve fetal oxygenation and placing the client on her side to enhance uterine perfusion. Questioning pain relief or readjusting the monitor does not address the issue, and internal monitoring may be considered but is not the first step.
An adolescent primiparous client 24 hours postpartum asks the nurse how often she should hold her neonate. Which of the following responses would be most appropriate?
- A. Hold him when he is fussy or crying.
- B. Hold him as much as you want to hold him.
- C. Try to hold him infrequently to avoid overstimulation.
- D. You can hold him periodically throughout the day.
Correct Answer: B
Rationale: Holding the neonate as much as desired promotes bonding and emotional security without risk of overstimulation.
While changing the neonate's diaper, the client asks the nurse about some red-tinged drainage from the neonate's vagina. Which of the following responses would be most appropriate?
- A. It's of no concern because it is such a small amount.
- B. The cause is usually related to swallowing blood during the delivery.
- C. Sometimes baby girls have this from hormones received from the mother.
- D. This vaginal spotting is caused by hemorrhagic disease of the newborn.
Correct Answer: C
Rationale: Pseudo-menstruation in female newborns is due to maternal hormone withdrawal.
The nurse is working with four clients on the obstetrical unit. Which client will be the highest priority for a cesarean section?
- A. Client at 40 weeks' gestation whose fetus weighs 8 lb by ultrasound estimate.
- B. Client at 37 weeks' gestation with fetus in ROP position.
- C. Client at 32 weeks' gestation with fetus in breech position.
- D. Client at 38 weeks' gestation with active herpes lesions.
Correct Answer: D
Rationale: Active herpes lesions necessitate a cesarean delivery to prevent neonatal transmission.
A neonate delivered at 40 weeks' gestation admitted to the nursery is found to be hypoglycemic. At 4 hours of age, the neonate appears pale and his pulse oximeter is reading 75 %. The nurse should:
- A. Increase the I.V. rate.
- B. Provide supplemental oxygen.
- C. Record the finding on the chart and repeat the reading in 30 minutes.
- D. Wrap the neonate to increase body temperature.
Correct Answer: B
Rationale: A pulse oximetry reading of 75% indicates hypoxemia, and providing supplemental oxygen is the priority.