Which of the following would the nurse most likely expect to find when assessing a pregnant client with abruption placenta?
The most common assessment finding in a client with abruption placenta is a rigid or boardlike abdomen. Pain, usually reported as a sharp stabbing sensation high in the uterine fundus with the initial separation, also is common.
A pregnant patient asks the nurse if she can take castor oil for her constipation. How should the nurse respond?
Castor oil can initiate premature uterine contractions in pregnant women. It also can produce other adverse effects, but it does not promote sodium retention. Castor oil is not known to increase absorption of fat-soluble vitamins, although laxatives, in general, may decrease absorption if intestinal motility is increased.
For a patient in active labor, the nurse-midwife plans to use an internal electronic fetal monitoring (EFM) device. What must occur before the internal EFM can be applied?
Internal EFM can be applied only after the patient’s membranes have ruptured when the fetus is at least at the -1 station, and when the cervix is dilated at least 2 cm. Although the patient may receive anesthesia, it is not required before the application of an internal EFM device.
Immediately after delivery, the nurse-midwife assesses the neonate’s head for signs of molding. Which factors determine the type of molding?
Fetal attitude—the overall degree of body flexion or extension—determines the type of molding in the head a neonate. Molding, is not influenced by maternal age, body frame, weight, parity, and gravidity or by maternal and paternal ethnic backgrounds.
A patient in her 14th week of pregnancy has presented with abdominal cramping and vaginal bleeding for the past 8 hours. She has passed several clots. What is the primary nursing diagnosis for this patient?
If bleeding and clots are excessive, this patient may become hypovolemic. Pad count should be instituted. Although the other diagnoses apply to this patient, they are not the primary diagnosis.
Which of the following would the nurse in charge do first after observing a 2-cm circle of bright red bleeding on the diaper of a neonate who just had a circumcision?
If bleeding occurs after the circumcision, the nurse should first apply gentle pressure on the area with sterile gauze. Bleeding is not common but requires attention when it occurs.
A client tells the nurse, “I think my baby likes to hear me talk to him.” When discussing neonates and stimulation with sound, which of the following would the nurse include as a means to elicit the best response?
Providing stimulation and speaking to neonates is important. Some authorities believe that speech is the most important type of sensory stimulation for a neonate. Neonates respond best to speech with tonal variations and a high-pitched voice. A neonate can hear all sounds louder than about 55 decibels.
While the client is in active labor with twins and the cervix is 5 cm dilates, the nurse observes contractions occurring at a rate of every 7 to 8 minutes in a 30-minute period. Which of the following would be the nurse’s most appropriate action?
The nurse should contact the physician immediately because the client is most likely experiencing hypotonic uterine contractions. These contractions tend to be painful but ineffective. The usual treatment is oxytocin augmentation unless cephalopelvic disproportion exists.
A 31-year-old multipara is admitted to the birthing room after initial examination reveals her cervix to be at 8 cm, completely effaced (100 %), and at 0 station. What phase of labor is she in?
The transitional phase of labor extends from 8 to 10 cm; it is the shortest but most difficult and intense for the patient. The active phase extends from 4 to 7 cm; it is moderate for the patient. The latent phase extends from 0 to 3 cm; it is mild in nature. The expulsive phase begins immediately after the birth and ends with separation and expulsion of the placenta.
A primigravida client at 25 weeks gestation visits the clinic and tells the nurse that her lower back aches when she arrives home from work. The nurse should suggest that the client perform:
Tailor sitting is an excellent exercise that helps to strengthen the client’s back muscles and also prepares the client for the process of labor. The client should be encouraged to rest periodically during the day and avoid standing or sitting in one position for a long time.
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