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Which of these women in the labor and delivery unit would the nurse check first when the water breaks (ROM) for all of them within a 2 minute period?
- A. A multigravida with station at +2, contractions at 15 minutes apart with duration of 30 seconds, cervix dilated at 7 cm, and 50% effacement
- B. A multigravida with station at -1, contractions at 15 minutes apart with duration of 30 seconds, cervix dilated at 3 cm, and 10% effacement
- C. A primipara with station at 0, contractions at 20 minutes apart with duration of 20 seconds, cervix dilated at 2 cm and 10% effacement
- D. A primipara with station at 1, contractions at 15 minutes apart with duration of 35 seconds, cervix dilated at 5 cm and 50% effacement
Correct Answer: B
Rationale: A multigravida with station at -1, contractions at 15 minutes apart with duration of 30 seconds, cervix dilated at 3 cm, and 10% effacement. When the station is -1 or -2 and the water breaks, the risk is greater for a prolapsed cord.
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Magnetic resonance imaging has been ordered for a client. Which factor should the nurse report to the physician?
- A. The client states she had an allergic reaction to iodine.
- B. The client has a pacemaker.
- C. The client wears a hearing aid.
- D. The client takes digoxin.
Correct Answer: B
Rationale: A pacemaker is a contraindication for MRI due to magnetic interference, requiring immediate physician notification to ensure safety.
The nurse is caring for a postoperative client who is unresponsive to painful stimuli and is given naloxone. Within 5 minutes, the client can be roused and responds to verbal commands. One hour later, the client is again difficult to rouse, with minimal response to physical stimuli. Which actions does the nurse anticipate? Select all that apply.
- A. Administration of oxygen
- B. Administration of a 2nd dose of naloxone
- C. Discontinuation of pain medication
- D. Initiation of a rapid response or code team
- E. Monitoring of respiratory rate
Correct Answer: A,B,E
Rationale: Recurrent unresponsiveness suggests opioid re-narcotization, requiring oxygen, a second naloxone dose, and respiratory monitoring. Discontinuing pain medication is premature, and rapid response is not yet indicated.
The primary nursing diagnosis for a client with congestive heart failure with pulmonary edema is
- A. Pain
- B. Impaired gas exchange
- C. Cardiac output altered: decreased
- D. Fluid volume excess
Correct Answer: C
Rationale: Cardiac output altered: decreased. Increasing cardiac output is the primary goal of therapy, improving comfort and respiratory status.
The LPN is caring for all of the following women on the postpartum unit. Which situation requires further attention?
- A. A woman who gave birth four hours ago has red vaginal drainage on her perineal pad.
- B. The nurse palpates the uterine fundus 3 cm above the umbilicus in a woman who gave birth 12 hours ago.
- C. A woman who had a 20-hour labor and gave birth 8 hours ago asks the nurse not to bring her baby in for breastfeeding during the night.
- D. A woman who gave birth yesterday is sweating profusely and producing large amounts of urine.
Correct Answer: B
Rationale: A fundus 3 cm above the umbilicus 12 hours postpartum suggests uterine atony or retained clots, requiring further assessment to prevent hemorrhage. Other findings are normal or less urgent.
The nurse is preparing a client for cervical uterine radiation implant insertion. Which will the nurse expect to be included in the teaching plan?
- A. TV or telephone use will not be allowed while the implant is in place.
- B. A Foley catheter is usually inserted.
- C. A high fiber diet is recommended.
- D. Excretions will be considered radioactive.
Correct Answer: B
Rationale: A catheter allows urine elimination without possible disruption of the implant. There is usually no restriction on TV or phone use, so answer A is incorrect. The client is placed on a low residue diet, so answer C is incorrect. The client's radiation is not internal; therefore, there are no special precautions with excretions, making answer D incorrect.