QUESTIONS AND DETAILED CORRECT ANSWERS | A+
GRADE VERIFIED ANSWERS
A nurse is caring for a client who is at 34 weeks of gestation and has preeclampsia.
A nurse is reviewing the client's electronic medical record. For each potential provider's prescription,
click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the
client.
Monitor blood pressure and respiratory status every 15 min.
Administer magnesium sulfate 4 g IV bolus.
Encourage the client to lay in a supine position.
Collect a urine specimen of culture and sensitivity.
Restrict hourly fluid intake to 125 mL/hr.
Keep lights dim.
the nurse should recognize that a prescription to encourage the client to lay in a supine position is
contraindicated. The nurse should encourage the client to lay in a side-lying position.
The nurse should anticipate the provider to prescribe dim lighting to decrease environmental
stimuli.
The nurse should anticipate the provider to prescribe a loading dose of magnesium sulfate 4 g IV
bolus, following by 2 g/hr maintenance dose.
The nurse should anticipate the provide to prescribe monitoring the client's blood pressure every 15
to 30 min.
The nurse should determine that collecting a urine specimen for culture and sensitivity is non-
essential for a client who has preeclampsia. The nurse should collect a urine specimen for culture
and sensitivity if the client presents with manifestations of a UTI.
The nurse should anticipate the provider restricting hourly fluid intake to 125 mL/hr.
A nurse is caring for a client who is in the second stage of labor.
The nurse observes retraction of the fetal head against the maternal perineum as the head is
birthed.
Complete the diagram by dragging from the choices below to specify what condition the client is
most likely experiencing, 2 actions the nurse should take to address that condition, and 2
parameters the nurse should monitor to assess the client's progress.
The nurse should flex the client's legs against the abdomen and apply suprapubic pressure because
the client is most likely experiencing shoulder dystocia. Flexing the clients legs against the abdomen
,straightens the maternal pelvis, helping to free the trapped anterior shoulder of the fetus. Applying
suprapubic pressure also helps free the anterior shoulder, allowing for birth of the newborn's body.
The nurse should monitor the movement of the newborn's upper extremities because newborns
who experience a shoulder dystocia are at a greater risk for brachial plexus injuries. The nurse
should also monitor the maternal perineum because mothers who experience shoulder dystocia are
at a greater risk for trauma to the vagina, perineum, and rectum.
A nurse at an antepartum clinic is admitting a client who is at 30 weeks of gestation.
Which of the following actions should the nurse take after administering the prescribed
medications? Select all that apply.
keep calcium gluconate readily available
check urinary output every 3 hours
check deep tendon reflexes every 1 hour
provide intermittent fetal monitoring
report respiratory rate of less than 12 breaths/min to the provider
Keep calcium gluconate available is correct. The nurse should have calcium gluconate readily
available because it is the antidote for magnesium toxicity.
Monitor urinary output every 2 hr is incorrect. The nurse should maintain strict hourly intake and
output.
Check deep tendon reflexes every 1 hr is correct. The nurse should assess deep tendon reflexes
every hour during continuous infusion of magnesium sulfate. The nurse should report to the
provider absence or loss of deep tendon reflexes.
Provide continuous fetal monitoring is incorrect. The nurse should provide continuous fetal
monitoring of the fetal heart rate and uterine contractions to assess for findings of placental
abruption and fetal well-being.
Report respiratory rate of less than 12 breaths/min to the provider is correct. The nurse should
report a respiratory rate less than 12/min to the provider because magnesium sulfate can cause
respiratory depression.
A nurse is caring for a client who is two days postpartum, is breast-feeding, and reports nipple
soreness. Which of the following measures should the nurse suggest to reduce discomfort during
breast-feeding?
Change the infant position on the nipples
Apply breast milk to the nipples before each feeding
Massage the breasts and nipples before feeding
Play breast pads inside the Nursing bra
Start breast-feeding with the nipple that is less sore
Change the infant position on the nipples
Apply breast milk to the nipples before each feeding
Start breast-feeding with the nipple that is less sore
signs of labor
preceding: lightening or dropping, bloody show
regular contractions, cervical effacement, dilation, rupture of the amnionic sac, fetal descent
true vs false labor
, True Labor → contractions w cervical dilation and shortening
False labor → irregular contractions (not progressively stronger), w/out cervical changes.
*SEDATION helps (key to distinguish)! Can reassure and d/c home.
5 major factors that affect the labor process
5 P's
Passage
Passenger
Powers
Position
Psyche
5 P's: passage
birth canal
- shape of pelvis (gynecoid = strongest association with vaginal delivery)
5 P's: passenger
fetus and placenta
- size
- presentation (ideal vertex - chin tucked)
- lie (relation of fetal spine to mother's)
- attitude (relation of fetal parts to one another; flexed or extend)
- position
5 P's: powers
- primary: involuntary (contractions)
-- cervical change
-- spontaneous or induced
- secondary: voluntary (pushing)
-- no effect on cervical change, fetal expulsion
5 P's: position
of the pregnant individual
- changes relieve fatigue, increase comfort, improve circulation
5 P's: psyche
Emotional State
- potential obstacles: stress, past experience, exhaustion, starvation/dehydration
Stages of Labor: First Stage
onset of labor to 10 cm
contains the 3 phases of labor
Phases of labor
latent/early: 0-5 cm (more effacement, less descent) active: 6-10 cm (rapid dilation, inc descent)