Nokea
Which of the following nursing diagnoses would be the priority for a multigravid diabetic client at 38 weeks' gestation who is scheduled for labor induction with oxytocin (Pitocin)?
- A. Risk for deficient fluid volume related to oxytocin infusion.
- B. Pain related to prolonged labor and uterine ischemia.
- C. Fear related to possible need for cesarean delivery.
- D. Risk for injury, maternal or fetal, related to potential uterine hyperstimulation.
Correct Answer: D
Rationale: Oxytocin can cause uterine hyperstimulation, risking maternal or fetal injury (e.g., fetal hypoxia). This is the priority in a diabetic client due to increased fetal vulnerability. Fluid volume, pain, and fear are less immediate.
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A primigravid client in active labor has had no anesthesia. The client's cervix is 7 cm dilated, and she is starting to feel considerable discomfort during the first 10 cm to the client's sacral client is a left side-lying position. The nurse should encourage which of the following?
- A. Rapid, shallow chest breathing.
- B. Deep chest breathing.
- C. Rapid pant-blow breathing.
- D. Slow abdominal breathing.
Correct Answer: D
Rationale: Slow abdominal breathing promotes relaxation and oxygenation, helping manage discomfort in active labor without anesthesia. Rapid or shallow breathing may lead to hyperventilation, and deep chest breathing is less effective for pain control.
A client asks about the use of over-the-counter contraceptives. Which of the following would the nurse recommend?
- A. Spermicides and male condoms.
- B. Female condoms and oral contraceptives.
- C. The contraceptive sponge and the patch.
- D. Emergency contraception pills and the diaphragm.
Correct Answer: A
Rationale: Spermicides and male condoms are available over-the-counter and effective when used correctly. Female condoms are also over-the-counter, but oral contraceptives, the patch, and diaphragms require prescriptions. Emergency contraception is over-the-counter but not for regular use.
A client asks about the risks of the copper IUD. Which of the following would the nurse include?
- A. It may increase menstrual bleeding and cramping.
- B. It causes permanent infertility.
- C. It requires daily replacement.
- D. It increases the risk of breast cancer.
Correct Answer: A
Rationale: The copper IUD may increase menstrual bleeding and cramping, especially initially. It does not cause permanent infertility, require daily replacement, or increase breast cancer risk.
Shortly after birth, the nurse measures the circumference of a term neonate's head and chest. When the two measurements are compared, which of the following would the nurse expect to find about the head circumference?
- A. Equal to the chest circumference.
- B. Approximately $2 \mathrm{~cm}$ larger than the chest.
- C. About $3 \mathrm{~cm}$ smaller than the chest.
- D. Approximately $4 \mathrm{~cm}$ larger than the chest.
Correct Answer: B
Rationale: In a term neonate, the head circumference is typically about 2 cm larger than the chest circumference.
A laboring client with preeclampsia is prescribed magnesium sulfate 2 g/hour I.V. piggyback. The pharmacy sends the I.V. to the unit labeled magnesium sulfate 20 g/500 mL normal saline. To deliver the correct dose, the nurse should set the pump to deliver how many milliliters per hour?
Correct Answer: 50
Rationale: To calculate the correct dose: (2 g/hour * 500 mL) / 20 g = 50 mL/hour.