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While the nurse is caring for a multiparous client in active labor at 36 weeks' gestation, the client tells the nurse, 'I think my water just broke.' Which of the following should the nurse do first?
- A. Turn the client to the right side.
- B. Assess the color, amount, and odor of the fluid.
- C. Assess the fetal heart rate pattern.
- D. Check the client's cervical dilation.
Correct Answer: C
Rationale: Rupture of membranes can affect fetal well-being, particularly in preterm labor (36 weeks). Assessing the fetal heart rate pattern first ensures the fetus is not in distress (e.g., due to cord compression). Fluid characteristics and dilation are assessed next.
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A 24-hour-old, full-term neonate is showing signs and possible signs. The nurse is assisting the physician with a lumbar puncture on this neonate. What should the nurse do to assist in this procedure? Select all that apply.
- A. Administer the I.V. antibiotic.
- B. Hold the neonate steady in the correct position.
- C. Ensure a patent airway.
- D. Maintain a sterile field.
- E. Obtain a serum glucose level.
Correct Answer: B,C,D
Rationale: Holding the neonate steady, ensuring a patent airway, and maintaining a sterile field are critical during a lumbar puncture to ensure safety and procedure success.
The physician orders an amniocentesis for a primigravid client at 35 weeks' gestation in early labor to determine fetal lung maturity. Which of the following is an indicator of fetal lung maturity?
- A. A amount of bilirubin present.
- B. Presence of red blood cells.
- C. Barr body determination.
- D. Lecithin-sphingomyelin (L/S ratio).
Correct Answer: D
Rationale: The lecithin-sphingomyelin (L/S) ratio in amniotic fluid is a key indicator of fetal lung maturity, with a ratio of 2:1 or higher indicating mature lungs. Bilirubin, red blood cells, and Barr body determination are not used for this purpose.
A primigravid client at 41 weeks' gestation is admitted to the hospital's labor and delivery unit in active labor. After 25 hours of labor with membranes ruptured for 24 hours, the client delivers a healthy neonate vaginally with a midline episiotomy. Which of the following nursing diagnoses should the nurse identify as the priority for the client?
- A. Activity intolerance related to difficult labor process.
- B. Sleep deprivation related to prolonged labor.
- C. Situational low self-esteem related to lengthy labor process.
- D. Risk for infection related to birth trauma and prolonged ruptured membranes.
Correct Answer: D
Rationale: Prolonged rupture of membranes (>24 hours) and episiotomy increase infection risk, making this the priority post-delivery. Activity intolerance, sleep deprivation, and self-esteem are less urgent.
During a scheduled cesarean delivery of a primigravid client with a fetus at 39 weeks' gestation in a breech presentation, a neonatologist is present in the operating room. The nurse explains to the client that the neonatologist is present because neonates born by cesarean delivery tend to have an increased incidence of which of the following?
- A. Congenital anomalies.
- B. Pulmonary hypertension.
- C. Meconium aspiration syndrome.
- D. Respiratory distress syndrome.
Correct Answer: D
Rationale: Cesarean delivery, especially without labor, increases the risk of respiratory distress syndrome due to retained lung fluid. Breech presentation may exacerbate this. Congenital anomalies, pulmonary hypertension, and meconium aspiration are less directly related.
A nurse is discussing preterm labor in a prenatal class. After class, a client and her partner ask the nurse to identify again the nursing strategies to prevent preterm labor. The clients need further instruction when they state which of the following?
- A. "I need to stay hydrated all the time."
- B. "I need to avoid any infections."
- C. "I should include frequent rest breaks if we travel."
- D. "Changing to filter cigarettes is helpful."
Correct Answer: D
Rationale: Smoking, even with filter cigarettes, is harmful and should be avoided.