Nokea
What is the most important assessment for the nurse to conduct following the administration of epidural anesthesia to a client who is at 40-weeks gestation?
- A. Level of pain sensation.
- B. Variability of fetal heart rate
- C. Maternal blood pressure
- D. Station of presenting part
Correct Answer: C
Rationale: Epidural anesthesia can cause a sudden drop in maternal blood pressure, which may affect placental perfusion, making blood pressure monitoring the priority.
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The nurse is caring for a client whose fetus died in utero at 32-weeks gestation. After the fetus is delivered vaginally, the nurse implements routine fetal demise protocol and identification procedures Which action is most important for the nurse to take?
- A. Explain reasons consent for an infant autopsy is needed
- B. Determine if the mother desires a visit from her clergy
- C. Encourage the mother to hold and spend time with her baby
- D. Create a memory box of baby's footprints and photographs
Correct Answer: C
Rationale: Encouraging the mother to hold and spend time with her baby supports the grieving process, helping her acknowledge and create memories with her child.
A client who delivered vaginally 2 days ago states that she wants to resume using her diaphragm for birth control. What information should the nurse share with her?
- A. The diaphragm must be refitted after childbirth
- B. The most effective form of contraception is a diaphragm
- C. The diaphragm should be inserted 2 to 4 hours before intercourse.
- D. Vaseline lubricant can be used when inserting the diaphragm
Correct Answer: A
Rationale: Childbirth can alter vaginal and cervical anatomy, requiring the diaphragm to be refitted for effective contraception.
A pregnant client receives Rho(D) immune globulin after an amniocentesis. The day following the procedure the client calls the nurse to report a temperature of 99.8° F (37.67°C). Which action should the nurse implement?
- A. Instruct the client to maintain bed rest for 24 hours.
- B. Encourage the client to increase her intake of oral fluids
- C. Schedule a visit with the healthcare provider today
- D. Verify the administered Rho(D) immune globulin's compatibility
Correct Answer: C
Rationale: A temperature elevation post-amniocentesis may indicate infection, requiring prompt evaluation by a healthcare provider.
The nurse examines a client who is admitted in active labor and determines the cervix is 3 cm dilated 50% effaced, and the presenting part is at 0 station. An hour later. she tells the nurse that she wants to go to the bathroom. Which action should the nurse implement first?
- A. Review the fetal heart rate pattern
- B. Check the pH of the vaginal fluid
- C. Determine cervical dilation.
- D. Palpate the client's bladder
Correct Answer: D
Rationale: A desire to use the bathroom may indicate a full bladder, which can impede labor progress. Palpating the bladder is the priority to assess this.
During a routine first trimester prenatal exam, a pregnant client tells the nurse that she has noticed an increase in vaginal discharge that is white, thin, and watery. Which action should the nurse implement?
- A. Notify the healthcare provider of the complaint
- B. Recommend an over-the-counter yeast medication
- C. Inform her that this is a normal physiological change.
- D. Prepare the client for a sterile speculum exam
Correct Answer: C
Rationale: Increased white, thin, watery discharge (leukorrhea) is a normal physiological change in pregnancy due to hormonal shifts, requiring no immediate intervention.