Nokea
When is the best time to administer a rubella vaccine to a client?
- A. After the client reaches 20-weeks gestation.
- B. Immediately, at 6-weeks gestation, to protect this fetus.
- C. Early postpartum, within 72 hours after delivery.
- D. After the client stops breastfeeding.
Correct Answer: C
Rationale: Administering the rubella vaccine postpartum within 72 hours ensures maternal immunity for future pregnancies without fetal risk, as it's a live vaccine contraindicated in pregnancy.
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A primipara presents to the perinatal unit describing rupture of the membranes (ROM) occurring 12 hours prior to coming to the hospital. An oxytocin infusion is begun, and 8 hours later the client's contractions are irregular and mild. Based on this data, the nurse plans to monitor which sign more frequently than for the average laboring client?
- A. Color of amniotic fluid.
- B. Maternal temperature.
- C. Deep tendon reflexes.
- D. Maternal blood pressure.
Correct Answer: B
Rationale: Prolonged ROM increases infection risk, necessitating frequent maternal temperature monitoring to detect chorioamnionitis early.
The nurse observes a fetal heart rate pattern on the monitor: baseline 160 beats per minute with minimal variability, a decrease to 150 beats per minute beginning after the contraction starts and returns to baseline after the contraction ends. Which finding should the nurse document in the electronic medical record?
- A. Variable decelerations.
- B. Late decelerations.
- C. No decelerations.
- D. Early decelerations.
Correct Answer: B
Rationale: The described pattern matches late decelerations, indicating potential utero-placental insufficiency, as the fetal heart rate decreases after the contraction starts and recovers post-contraction.
A primipara client at 42 weeks gestation is admitted for induction. Within one hour after initiating an oxytocin infusion, her cervix is 100% effaced and 6 cm dilated, contractions are occurring every 1 minute with a 75-second duration. The nurse stops the oxytocin and starts oxygen. After 30 minutes of uterine rest, the contractions are occurring every 5 minutes with 20-second duration. Which intervention should the nurse implement?
- A. Notify the nursery about the client's response.
- B. Restart oxytocin infusion rate per protocol.
- C. Stop oxygen per cannula.
- D. Check for clonus in both feet.
Correct Answer: B
Rationale: Restarting oxytocin per protocol resumes labor induction safely after uterine rest, ensuring continued progress without hyperstimulation.
During a routine prenatal visit, a client at 32-weeks gestation reports that urinary frequency has increased during the day as well as at night. The nurse determines the client is having irregular uterine contractions. Which action should the nurse implement?
- A. Collect a urine sample for dipstick analysis.
- B. Ask the client if she had sexual intercourse yesterday.
- C. Obtain a midstream urine specimen for culture.
- D. Determine if she has a change in vaginal discharge.
Correct Answer: C
Rationale: A midstream urine culture diagnoses UTIs, which can cause urinary frequency and uterine irritability, guiding targeted treatment.
A woman in her third trimester of pregnancy has been in active labor for the past 8 hours and has dilated 3 cm. The nurse's assessment findings and electronic fetal monitoring (EFM) are consistent with hypotonic dystocia, and the healthcare provider (HCP) prescribes an oxytocin drip. Which data is most important for the nurse to monitor?
- A. Preparation for emergency cesarean birth.
- B. Intensity, interval, and length of contractions.
- C. Checking the perineum for bulging.
- D. Client's hourly blood pressure.
Correct Answer: B
Rationale: Monitoring contraction patterns ensures oxytocin efficacy and prevents hyperstimulation in hypotonic dystocia, critical for labor progression.