The Nclex-Rn® Examination, 7Th Edition (Maternity ) 2024
A newly pregnant client is crying loudly and reports to the clinic nurse over the phone that she took a prescribed narcotic pain medication 4 weeks ago. What is the nurse’s next response? Correct Answer A “You have nothing to worry about.” B “When did your last period begin?” C “Come to the clinic today for an ultrasound.” D “I’ll let your health care provider know.” Rationale: Begin with an assessment to determine how pregnant the client is. Determine if she ingested the narcotic during the pre-embryonic period, or the time when the fertilized egg is passing through the fallopian tubes. If the embryo is not attached to maternal circulation, there is no cause for concern. Do not offer false reassurance. Data needs to be collected first. Perform noninvasive, low-cost assessments first. The healthcare provider needs to be notified if there is a cause for concern The nurse is evaluating a full-term multigravida who was induced 3 hours ago. The nurse determines that the client is dilated 7 cm and is 100% effaced at 0 station, with intact membranes. The monitor indicates that the FHR decelerates at the onset of several contractions and returns to baseline before each contraction ends. Which action should the nurse take next? Correct Answer A Reapply the external transducer. B Insert the intrauterine pressure catheter. C Discontinue the oxytocin infusion. D Continue to monitor labor progress. Rationale: The fetal heart rate indicates early decelerations, which are not an ominous sign, so the nurse should continue to monitor the labor progress and document the findings in the client’s record. There is no reason to reapply the external transducer if the FHR tracings are being captured. Options B and C are not indicated at this time. When assessing a client at 12 weeks of gestation, the nurse recommends that she and her husband consider attending childbirth preparation classes. When is the best time for the couple to attend these classes? Correct Answer A At 16 weeks of gestation
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