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The RN is delegating tasks to the unlicensed assistive personnel (UAP). Which tasks can the nurse delegate?
- A. Teaching the patient about breast care
- B. Assessment of a patient's lochia and perineal area
- C. Assisting a patient to the bathroom for the first time after birth
- D. Vital signs on a postpartum patient who delivered the night before
Correct Answer: D
Rationale: Nurses can delegate stable, routine tasks like taking vital signs or assisting with noncritical activities but cannot delegate assessments or teaching.
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The nurse assesses a client admitted to the labor and delivery unit and obtains the following data: dark red vaginal bleeding, uterus slightly tense between contractions, BP 110/68, FHR 110 beats/minute, cervix 1 cm dilated and uneffaced. Based on these assessment findings, what intervention should the nurse implement?
- A. Insert an internal fetal monitor
- B. Assess for cervical changes q1h
- C. Monitor bleeding from IV sites
- D. Perform Leopold's maneuvers
Correct Answer: C
Rationale: Monitoring bleeding from peripheral sites (C) is the priority intervention. This client is presenting with signs of placental abruption. Disseminated intravascular coagulation (DIC) is a complication of placental abruption, characterized by abnormal bleeding.
A 42-week gestational client is receiving an intravenous infusion of oxytocin (Pitocin) to augment early labor. The nurse should discontinue the oxytocin infusion for which pattern of contractions?
- A. Transition labor with contractions every 2 minutes, lasting 90 seconds each
- B. Early labor with contractions every 5 minutes, lasting 40 seconds each
- C. Active labor with contractions every 31 minutes, lasting 60 seconds each
- D. Active labor with contractions every 2 to 3 minutes, lasting 70 to 80 seconds each
Correct Answer: A
Rationale: Contractions pattern (A) describes hyperstimulation and an inadequate resting time between contractions to allow for placental perfusion. The oxytocin infusion should be discontinued.
A woman who had a miscarriage 6 months ago becomes pregnant. Which instruction is most important is most important for the nurse to provide this client?
- A. Elevate lower legs while resting
- B. Increase caloric intake by 200 to 300 calories per day
- C. Increase water intake to 8 full glasses per day
- D. Take prescribed multivitamin and mineral supplements
Correct Answer: D
Rationale: A client who has had a spontaneous abortion or stillbirth in the last 1.5 years should take multivitamin and mineral supplements (D) and maintain a balanced diet because the previous pregnancy may have left her nutritionally depleted.
A client at 39-weeks gestation is admitted to the labor and delivery unit in active labor. The client's cervix is dilated 7 cm, 100% effaced, and the fetus is at +1 station. The client begins to push forcefully with contractions. What action should the nurse take?
- A. Encourage the client to pant-blow during contractions.
- B. Assist the client to push with contractions.
- C. Prepare for an immediate delivery.
- D. Notify the healthcare provider.
Correct Answer: A
Rationale: Pant-blow breathing helps prevent premature pushing before full dilation, reducing the risk of cervical edema.
A term multigravida, who is receiving oxytocin for labor augmentation is requesting pain medication. Review of the clients record indication that she was medicated 30 minutes ago with butorphanol (Stadol) 2 mg and promethazine (Phenergan) 25 mg IV push. Vaginal examination reveals that the client cervical dilation is 3 cm, 70% effaced, and at a 0 station. What action should the nurse implement?
- A. Discontinue the Pitocin infusion
- B. Medicate the client with an additional 1 mg of Stadol IV push
- C. Notify the healthcare provider
- D. Instruct the client to use deep breathing during contraction
Correct Answer: D
Rationale: Deep breathing techniques (D) can help manage pain without additional medication.