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While caring for a moderately obese primigravid client in active labor at term, the nurse should monitor the client for signs of which of the following?
- A. Hypotonic reflexes.
- B. Increased uterine resting tone.
- C. Soft tissue dystocia.
- D. Increased fear and anxiety.
Correct Answer: C
Rationale: Obesity in labor increases the risk of soft tissue dystocia due to excess pelvic fat impeding fetal descent. Hypotonic reflexes are not typically associated with obesity, increased uterine resting tone is more related to hyperstimulation, and while anxiety may occur, it is not specific to obesity-related complications.
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The nurse in a postpartum couplet room is making rounds prior to ending the shift. Which of the following indicate that the safety needs of the clients have been met?
- A. Infant lying on abdomen.
- B. Security tags in place.
- C. Identification system on mother and infant.
- D. Bulb syringe within sight.
- E. Someone in room able to care for infant.
- F. Infant in the mother's bed, side rails up.
- G. Infant in the mother's arms, both asleep.
Correct Answer: B,C,D,E
Rationale: Safety needs are met with security tags, identification systems, a bulb syringe for suctioning, and someone present to care for the infant.
A 16-year-old primigravid client, with a history of attending one prenatal visit, is admitted to the hospital in active labor at 37 weeks' gestation. Her cervix is 7 cm dilated with the presenting part at 0 station. She enters the labor unit appearing anxious and hyperventilating. Because of the hyperventilation, the nurse should assess the client for:
- A. Metabolic alkalosis.
- B. Metabolic acidosis.
- C. Respiratory alkalosis.
- D. Respiratory acidosis.
Correct Answer: C
Rationale: Hyperventilation causes excessive exhalation of carbon dioxide, leading to respiratory alkalosis (elevated blood pH). Metabolic imbalances are less likely, and respiratory acidosis occurs with hypoventilation.
A primigravid client with class II heart disease who is visiting the clinic at 8 weeks' gestation tells the nurse that she has been maintaining a low-sodium, 1,800-calorie diet. Which of the following instructions should the nurse give the client?
- A. Avoid folic acid supplements to prevent megaloblastic anemia.
- B. Severely restrict sodium intake throughout the pregnancy.
- C. Take iron supplements with milk to enhance absorption.
- D. Increase caloric intake to 2,200 calories daily to promote fetal growth.
Correct Answer: D
Rationale: Increased caloric intake supports fetal growth without compromising maternal health.
A client is considering the hormonal IUD. Which of the following client statements indicates a need for further teaching?
- A. The IUD may reduce my menstrual bleeding.
- B. The IUD can stay in place for several years.
- C. The IUD will prevent ovulation every month.
- D. The IUD does not protect against STIs.
Correct Answer: C
Rationale: The hormonal IUD does not primarily prevent ovulation every month; it mainly thins the uterine lining and thickens cervical mucus. The other statements are correct, indicating a need for further teaching.
When developing the initial plan of care for a neonate who was born at 41 weeks' gestation, was diagnosed with meconium aspiration syndrome (MAS), and requires mechanical ventilation, which of the following should the nurse include:
- A. Care of an umbilical arterial line.
- B. Frequent ultrasound scans.
- C. Orogastric feedings as soon as possible.
- D. Assessment for symptoms of hyperglycemia.
Correct Answer: A
Rationale: Care of an umbilical arterial line is necessary for monitoring blood gases and blood pressure in a neonate on mechanical ventilation.