What side effect should the nurse inform the patient that she might experience?
- A. Nausea and vomiting
- B. Headache
- C. Warm flush
- D. Urinary frequency
Correct Answer: C
Rationale: Magnesium sulfate is the drug of choice for initiating therapy to stop labor. The patient will notice a warm flush with the initiation of the drug.
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What is the nurse's initial action?
- A. Stop the oxytocin infusion.
- B. Continue the infusion and report the findings to the physician.
- C. Turn her on her left side and reassess the contractions.
- D. Administer oxygen by mask.
Correct Answer: A
Rationale: Oxytocin is discontinued if signs of fetal compromise or excessive uterine contractions occur.
What is this labor pattern considered?
- A. Normal
- B. Hypotonic
- C. Hypertonic
- D. FALSE
Correct Answer: B
Rationale: The woman with labor dysfunction related to decreased uterine muscle tone begins labor normally, but contractions diminish after the active phase.
What should the nurse assess for in the newborn?
- A. Loss of hair from contact with forceps
- B. Sacral hematoma
- C. Facial asymmetry
- D. Shoulder dislocation
Correct Answer: C
Rationale: Pressure from forceps may injure the infant's facial nerve, which is evidenced by facial asymmetry.
What does the nurse explain is used to soften the cervix with a 'cervical ripening' agent?
- A. Prostaglandin gel insertion
- B. Intravenous oxytocin
- C. Warm saline douches
- D. Nipple stimulation
Correct Answer: A
Rationale: Prostaglandin gel is inserted in the cervix and the woman remains in bed for 1 to 2 hours, being monitored for uterine contractions.
How might the nurse instruct the patient to stimulate her nipples in an attempt to increase the quality of uterine contractions?
- A. Place a warm, moist washcloth over the breast.
- B. Brush the nipples with a dry washcloth.
- C. Gently pull on the nipples.
- D. Apply suction to the nipples with a breast pump.
- E. Press the palms of her hands down on her breasts.
Correct Answer: B,C,D
Rationale: Brushing nipples with a dry washcloth, gently pulling nipples, and applying suction with a breast pump are effective methods to increase uterine contractions.
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