While assessing a primipara during the immediate postpartum period, the nurse in charge plans to use both hands to assess the client’s fundus to:
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Solution
Prevent uterine inversion
Using both hands to assess the fundus is useful for preventing uterine inversion.
The multigravida mother with a history of rapid labor who us in active labor calls out to the nurse, “The baby is coming!” which of the following would be the nurse’s first action?
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Solution
Inspect the perineum
When the client says the baby is coming, the nurse should first inspect the perineum and observe for crowning to validate the client’s statement. If the client is not delivering precipitously, the nurse can calm her and use appropriate breathing techniques.
While caring for a multigravida client in early labor in a birthing center, which of the following foods would be best if the client requests a snack?
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Solution
Yogurt
In some birth settings, intravenous therapy is not used with low-risk clients. Thus, clients in early labor are encouraged to eat healthy snacks and drink fluid to avoid dehydration. Yogurt, which is an excellent source of calcium and riboflavin, is soft and easily digested. During pregnancy, gastric emptying time is delayed. In most hospital settings, clients are allowed only ice chips or clear liquids.
A client with eclampsia begins to experience a seizure. Which of the following would the nurse in charge do first?
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Solution
Maintain a patent airway
The priority for the pregnant client having a seizure is to maintain a patent airway to ensure adequate oxygenation to the mother and the fetus. Additionally, oxygen may be administered by face mask to prevent fetal hypoxia.
When preparing a teaching plan for a client who is to receive a rubella vaccine during the postpartum period, the nurse in charge should include which of the following?
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Solution
Pregnancy should be avoided for 3 months after the immunization
After administration of rubella vaccine, the client should be instructed to avoid pregnancy for at least 3 months to prevent the possibility of the vaccines toxic effects to the fetus.
A primigravida client at about 35 weeks gestation in active labor has had no prenatal care and admitted to cocaine use during the pregnancy. Which of the following persons must the nurse notify?
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Solution
Physician who will attend the delivery of the infant
The fetus of a cocaine-addicted mother is at risk for hypoxia, meconium aspiration, and intrauterine growth retardation (IUGR). Therefore, the nurse must notify the physician of the client’s cocaine use because this knowledge will influence the care of the client and neonate. The information is used only in relation to the client’s care.
After teaching a pregnant woman who is in labor about the purpose of the episiotomy, which of the following purposes stated by the client would indicate to the nurse that the teaching was effective?
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Solution
Shortens the second stage of labor
An episiotomy serves several purposes. It shortens the second stage of labor, substitutes a clean surgical incision for a tear, and decreases undue stretching of perineal muscles. An episiotomy helps prevent tearing of the rectum but it does not necessarily relieves pressure on the rectum. Tearing may still occur.
What is the approximate time that the blastocyst spends traveling to the uterus for implantation?
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Solution
7 days
The blastocyst takes approximately 1 week to travel to the uterus for implantation.
When administering magnesium sulfate to a client with preeclampsia, the nurse understands that this drug is given to:
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Solution
Prevent seizures
The chemical makeup of magnesium is similar to that of calcium and, therefore, magnesium will act like calcium in the body. As a result, magnesium will block seizure activity in a hyper-stimulated neurologic system by interfering with signal transmission at the neuromuscular junction.
A client with type 1 diabetes mellitus who is a multigravida visits the clinic at 27 weeks gestation. The nurse should instruct the client that for most pregnant women with type 1 diabetes mellitus:
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Solution
Nonstress testing is performed weekly until 32 weeks’ gestation
For most clients with type 1 diabetes mellitus, non-stress testing is done weekly until 32 weeks’ gestation and twice a week to assess fetal well-being.