ANSWERS GUARANTEE A+
✔✔A primipara client at 42 weeks gestation is admitted for induction. Within one hour
after initiating an oxytocin infusion, her cervix is 100% effaced and 6 cm dilated,
contractions are occurring every 1 minute with a 75 second duration. The nurse stops
the oxytocin and starts oxygen. After 30 minutes of uterine rest, the contractions are
occurring every 5 minutes with 20 second duration. What intervention should the nurse
implement?
A. Notify nursery about the client's response.
B. Check for clonus in both feet.
C. Stop oxygen per cannula.
D. Restart oxytocin infusion rate per protocol. - ✔✔D. Restart oxytocin infusion rate per
protocol.
✔✔At 0600 while admitting a woman for a scheduled repeat cesarean section, the client
tells the nurse that she drank a cup of coffee at 0400 because she wanted to avoid
getting a headache. What action would the nurse take first?
A. Ensure preoperative lab results are available.
B. Inform the anesthesia care provider.
C. Start prescribed IV with Lactated Ringer's.
D. Contact the client's obstetrician. - ✔✔B. Inform the anesthesia care provider.
✔✔The nurse is caring for a postpartum client who is exhibiting symptoms of a spinal
headache 24 hours following delivery of a normal newborn. Prior to the
anesthesiologists arrival on the unit, which action should the nurse perform?
A. Cleanse the spinal injection site.
B. Place procedure equipment at bedside.
C. Apply an abdominal binder.
D. Insert an indwelling Foley catheter. - ✔✔B. Place procedure equipment at bedside.
✔✔A primigravida arrives at the observation unit of the maternity unit because she
thinks she is in labor. The nurse applies the external fetal heart monitor and determines
that the fetal heart rate is 140 beats/minute and contractions are occurring irregularly
every 10-15 minutes. Which assessment finding confirms to the nurse that the client is
not in labor at this time?
A. Contractions decrease with walking.
B. 2+ pitting edema in lower extremities.
C. Cervical dilations is 1cm.
D. Membranes are intact. - ✔✔A. Contractions decrease with walking.
✔✔A multigravida client in labor is receiving oxytocin 4mu/minute to help promote an
effective contraction pattern. The available solution is Lactacted Ringer's 1,000 mL with
oxytocin 20 units. The nurse should program the infusion pump to deliver how many
mL/hr? - ✔✔12
, ✔✔A primigravida client with gestational hypertension and a Bishop score of 3 is
scheduled for induction of labor. The nurse administers misoprostol at 0700, then
observes regular contractions with cervical changes at 0900. Which action should the
nurse take?
A. Administer misoprostol every 2hrs.
B. Ambulate the client after administration of misoprostol.
C. Start oxytocin infusion immediately.
D. Begin oxytocin 4hrs after misoprostol is given. - ✔✔D. Begin oxytocin 4hrs after
misoprostol is given.
✔✔The nurse is caring for a client whose fetus died in utero at 32 weeks gestation.
After the fetus is delivered vaginally, the nurse implements routine fetal demise protocol
and identification procedures. Which action is important for the nurse to take?
A. Explain reasons consent for an infant autopsy is needed.
B. Encourage the mother to hold and spend time with her baby.
C. Determine if the mother desires a visit from her clergy.
D. Create a memory box of baby's footprints and photographs. - ✔✔B. Encourage the
mother to hold and spend time with her baby.
✔✔Following a minor motor vehicle collision, a client at 36-weeks gestation is brought
to the emergency center. She is lying supine on a backboard, is awake, and denies any
complaints. Her blood pressure is 80/50 mmHg and heart rate is 130 bpm. Which action
should the nurse implement first?
A. Palpate the abdomen for contractions.
B. Tilt the backboard sideways to displace the uterus laterally.
C. Obtain a blood sample for complete blood count.
D. Infuse 1,000 mL normal saline using a large bare IV. - ✔✔B. Tilt the backboard
sideways to displace the uterus laterally.
✔✔A new mother asks the nurse about an area of swelling on her baby's head near the
posterior fontanel that lies across the suture line. How should the nurse respond?
A. "That is called caput succedaneum. It will have to be drained."
B. "That is called caput succedaneum. It will absorb and cause no problems."
C. "That is called a cephalhematoma. It will cause no problems."
D. "That is called a cephalhematoma. It can cause jaundice as it is absorbed." - ✔✔B.
"That is called caput succedaneum. It will absorb and cause no problems."
✔✔A client at 35 weeks gestation complains of a "pain whenever the baby moves". On
assessment, the nurse notes the client's temperature to be 101.2F with severe
abdominal or uterine tenderness on palpation. The nurse knows that these findings are
indicative of which condition?
A. Round ligament strain.
B. Viral infection
C. Abruptio placenta