Nokea
A nurse is caring for a client who is in the transition phase of labor. Which of the following...
- A. Assist the client to void every 3 hr.
- B. Monitor contractions every 30 min.
- C. Place the client into a lithotomy position.
- D. Encourage the client to use a pant-blow breathing pattern.
Correct Answer: B
Rationale: The correct answer is B: Monitor contractions every 30 min. During the transition phase of labor, contractions are typically intense and frequent. Monitoring contractions every 30 minutes allows the nurse to assess the progress of labor and ensure the safety of both the mother and the baby. This helps in identifying any abnormalities or complications that may arise during this critical stage.
A: Assisting the client to void every 3 hr is important, but it is not specific to the transition phase of labor.
C: Placing the client into a lithotomy position is not recommended during the transition phase as it can restrict blood flow and increase the risk of complications.
D: Encouraging the client to use a pant-blow breathing pattern is a relaxation technique more suited for the earlier stages of labor, not the transition phase.
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The nurse is monitoring a client with severe preeclampsia. What finding requires immediate intervention?
- A. Proteinuria of +1.
- B. Respiratory rate of 16 breaths per minute.
- C. Deep tendon reflexes +4.
- D. Urine output of 50 mL/hour.
Correct Answer: C
Rationale: The correct answer is C: Deep tendon reflexes +4. In severe preeclampsia, increased reflexes indicate possible progression to eclampsia with seizures. Immediate intervention is needed to prevent seizures. Choice A is not urgent unless higher proteinuria levels are present. Choice B is within normal range. Choice D is concerning but not as urgent as managing potential seizures.
The nurse is caring for a client in labor with a history of cesarean delivery. What is a priority assessment?
- A. Assess for signs of uterine rupture.
- B. Monitor maternal temperature hourly.
- C. Check for signs of preeclampsia.
- D. Assess for excessive fetal movement.
Correct Answer: A
Rationale: The correct answer is A: Assess for signs of uterine rupture. This is the priority assessment because a history of cesarean delivery puts the client at higher risk for uterine rupture during labor. Signs of uterine rupture include severe abdominal pain, abnormal fetal heart rate patterns, and vaginal bleeding. Early detection and intervention are crucial for the safety of both the mother and the baby. Monitoring maternal temperature (B) is important but not as critical as assessing for uterine rupture. Checking for signs of preeclampsia (C) is also important but not a priority in this specific scenario. Assessing for excessive fetal movement (D) is not a priority assessment in this case.
Upon delivery of the newborn, the nursing intervention that most promotes parental attachment is:
- A. Placing the infant under the radiant warmer
- B. Allowing the mother to rest immediately after delivery
- C. Placing the newborn on mother's chest and abdomen
- D. Taking the newborn to the nursery for the initial assessment
Correct Answer: C
Rationale: The correct answer is C: Placing the newborn on mother's chest and abdomen. This promotes parental attachment through skin-to-skin contact, facilitating bonding and emotional connection. It also helps regulate the baby's temperature and encourage breastfeeding. Placing the infant under the radiant warmer (A) may disrupt immediate bonding. Allowing the mother to rest (B) is important, but promoting attachment should be prioritized. Taking the newborn to the nursery (D) can delay the crucial bonding process.
Which herbs would you counsel a lactating client to use to stimulate blood flow to the breast glands, stimulate milk production, and enrich milk flow?
- A. Milk thistle
- B. Cabbage juice
- C. Lanolin
- D. Aloe vera
Correct Answer: B
Rationale: The correct answer is B: Cabbage juice. Cabbage juice contains phytoestrogens that help stimulate blood flow to the breast glands and promote milk production. It is used traditionally to increase milk supply in lactating women. Milk thistle (A) is more commonly used for liver health and not specifically for lactation. Lanolin (C) is a topical ointment for sore nipples, not for milk production. Aloe vera (D) is not recommended for internal use during lactation due to potential laxative effects. In summary, cabbage juice is the best choice as it directly supports milk production and flow in lactating clients.
The nurse is caring for a client with suspected preterm labor. Which medication is most likely to be prescribed?
- A. Magnesium sulfate.
- B. Methyldopa.
- C. Rho(D) immune globulin.
- D. Oxytocin.
Correct Answer: A
Rationale: The correct answer is A: Magnesium sulfate. This medication is commonly prescribed for preterm labor to relax the uterine muscles and prevent contractions. It helps delay labor and reduce the risk of preterm birth. Methyldopa (B) is used for managing hypertension, not preterm labor. Rho(D) immune globulin (C) is given to Rh-negative mothers to prevent hemolytic disease in newborns. Oxytocin (D) is used to induce or augment labor, not for suspected preterm labor. Therefore, A is the most appropriate choice for managing preterm labor.