Nokea
While assessing the prenatal client, the nurse found a number of concerning problems. Place the concerning problems in the sequence that they should be addressed by the nurse.
- A. Currently bleeding and cramping
- B. Previous varicella infection
- C. Currently using tobacco
- D. Has intense pelvic pain
Correct Answer: D,A,C,B
Rationale: Has intense pelvic pain is most concerning and should be addressed first by the nurse. It could be a symptom of a serious medical condition, such as a miscarriage, ectopic pregnancy, or appendicitis. This symptom represents a possible pathology that could warrant immediate surgical intervention. Currently bleeding and cramping should be addressed next. It could be associated with the pelvic pain and could be a symptom of a serious medical condition, such as a miscarriage or ectopic pregnancy. Currently using tobacco can put the client at risk for multiple adverse outcomes and should be addressed, although it is not an immediately concerning factor. Previous varicella infection is important to document but poses no risk to the client or the fetus, so it is the least important to address.
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When looking in the mirror at her abdomen, the postpartum client says to the nurse, “My stomach still looks like I’m pregnant!” The nurse explains that the abdominal muscles, which separate during pregnancy, will undergo which change?
- A. Regain tone Within the first week after birth
- B. Regain prepregnancy tone with exercise
- C. Remain separated, giving the abdomen a slight bulge
- D. Regain tone as the weight gained during pregnancy is lost
Correct Answer: B
Rationale: For most women, it takes about 6 weeks (not one week) to regain abdominal wall muscle tone to the prepregnancy state, and usually only with exercise. The “still-pregnant” appearance is caused by relaxation of the abdominal wall muscles. With exercise, most women can regain prepregnancy abdominal muscle tone within about 6 weeks. If the client delivers a very large infant, the abdominal muscles may separate, but the separation will become less apparent over time. Weight loss alone will not strengthen the abdominal muscles.
The client in labor is requesting water therapy (hydrotherapy) to help provide pain relief and relaxation. Her recent vaginal exam was 2/50/—2. How should the nurse respond to the client’s request?
- A. “Usually we initiate hydrotherapy during active labor.”
- B. “You will not need to change positions quite as much.”
- C. “We will not be able to monitor fetal heart rate as easily.”
- D. “You can use hydrotherapy for up to 60 minutes at a time.”
Correct Answer: A
Rationale: Hydrotherapy is usually initiated when the client is in active labor, at approximately 4 or 5 cm. This timing will help reduce the risk of prolonged labor and provide a welcome change when the contractions are becoming stronger and closer together. Changing position takes less effort while immersed in water, so women are encouraged to change positions more frequently to help facilitate the process of labor. FHR monitoring can be done just as easily during hydrotherapy, using a wireless external monitor, Doppler, or fetoscope. Internal electrodes can be placed during most types of hydrotherapy but is contraindicated during jet hydrotherapy. There is no time limit for laboring women to use hydrotherapy; they may stay as long as desired, unless complications develop during the labor process.
The nurse prepares the client for which pain management option during labor?
- A. Epidural anesthesia
- B. Hot baths during active labor
- C. Over-the-counter pain relievers
- D. No pain relief options
Correct Answer: A
Rationale: Epidural anesthesia is a common and effective pain management option during labor, tailored to the client's needs.
The first-trimester pregnant client asks the nurse if the activities in which she participates are safe in the first trimester. Which activity should the nurse verify as a safe activity during the client’s first trimester?
- A. Hair coloring
- B. Hot tub use
- C. Pesticide use
- D. Sexual activity
Correct Answer: D
Rationale: Sexual activity is not contraindicated in pregnancy unless a specific risk factor is identified. Hair coloring should be avoided in the first trimester because the chemicals can be absorbed and pose a risk to the developing fetus. Hot tub use should be avoided because it increases the client’s body temperature. Maternal hyperthermia during the first trimester raises concerns about possible spontaneous abortion, CNS defects, and failure of neural tube closure. Exposure to pesticides during pregnancy increases the risk for preterm birth, intrauterine growth restriction, childhood developmental delays, and infertility later in adulthood.
The laboring client is requesting IV pain medication instead of epidural anesthesia. The nurse determines that which factor would most definitely contraindicate the administration of nalbuphine hydrochloride?
- A. Completely dilated and 100 percent effaced
- B. Fetal heart rate (FHR) of 120 beats per minute
- C. Reassuring FHR variability and accelerations
- D. Variable decelerations with reassuring FHR
Correct Answer: A
Rationale: Systemic medications, such as nalbuphine hydrochloride (Nubain), should not be administered when advanced dilation is present (transition stage of labor) because its use can lead to respiratory depression if given too close to the time of delivery. An FHR of 120 bpm is within normal parameters of 120 to 160 bpm. Reassuring FHR variability and accelerations are interpreted as adequate placental oxygenation and do not contraindicate administration of nalbuphine hydrochloride. If mild variable decelerations are present but the FHR pattern remains reassuring, nalbuphine hydrochloride can still be administered.