Nokea
Two hours ago, a multigravid client was admitted in active labor with her cervix dilated at 5 cm and completely effaced and the fetus at 0 station. Currently, the client is experiencing nausea and vomiting, a slight chill with perspiration beads on her lip, and extreme irritability. The nurse should first:
- A. Warm the temperature of the room by a few degrees.
- B. Increase the rate of intravenous fluid administration.
- C. Obtain an order for an intramuscular antiemetic medication.
- D. Assess the client's cervical dilation and station.
Correct Answer: D
Rationale: Nausea, chills, perspiration, and irritability are signs of the transition phase (8–10 cm dilation). Assessing cervical dilation and station confirms progression and guides care. Warming the room, increasing fluids, or administering antiemetics are secondary.
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In which of the following maternal locations would the nurse place the ultrasound transducer of the external electronic fetal heart rate monitor if a fetus at 34 weeks' gestation is in the left occipitoanterior(LOA) position?
- A. Near the symphysis pubis.
- B. Two inches above the umbilicus.
- C. Below the umbilicus on the left side.
- D. At the level of the umbilicus.
Correct Answer: C
Rationale: The transducer should be placed below the umbilicus on the left side for LOA position.
A client asks about the benefits of a hormonal IUD. Which of the following would the nurse include?
- A. It provides protection against STIs.
- B. It can reduce menstrual bleeding over time.
- C. It requires replacement every 6 months.
- D. It is not suitable for women with heavy periods.
Correct Answer: B
Rationale: A hormonal IUD can reduce menstrual bleeding over time, often leading to lighter periods or amenorrhea. It does not protect against STIs, lasts 3-7 years, and is suitable for heavy periods.
After the physician explains the prognosis and medical management for atrial septal defect to a primiparous client whose 2-day-old female neonate was diagnosed with this condition, the nurse determines that the mother needs further instructions when she says which of the following?
- A. As my child grows, she may have increased fatigue and difficulty breathing.'
- B. My child may need to have antibiotics if she develops an infection.'
- C. This condition occurs more commonly in females than in males.'
- D. About half of the children born with this defect heal spontaneously.'
Correct Answer: C
Rationale: Atrial septal defects are not significantly more common in females, indicating a need for further instruction.
A multigravid client is in active labor with twins at 38 weeks' gestation. The nurse should monitor the client closely for symptoms of which of the following?
- A. Pregnancy-induced hypertension.
- B. Urinary tract infection.
- C. Chorioamnionitis.
- D. Precipitous delivery.
Correct Answer: D
Rationale: Twin pregnancies increase the risk of precipitous delivery due to uterine overdistension, which can lead to rapid labor. Hypertension, infections, or chorioamnionitis are possible but less specific to twins.
When developing the plan of care for a multiparous client in active labor who receives an epidural anesthetic, which of the following would the nurse anticipate that the physician will order if the client develops moderate hypotension?
- A. Ephedrine sulfate.
- B. Epinephrine (Adrenalin Chloride).
- C. Methylergonovine (Methergine).
- D. Atropine sulfate.
Correct Answer: A
Rationale: Ephedrine sulfate is commonly used to treat epidural-related hypotension by increasing blood pressure through vasoconstriction and cardiac stimulation. Epinephrine is for emergencies, methylergonovine treats uterine atony, and atropine addresses bradycardia.