Intrapartum Exam (elaborations) NUR 1600

Question 1 See full question A 39-year-old multiparous client at 39 weeks’ gestation diagnosed with class II heart disease is admitted to the hospital in active labor. What should the nurse assess first after admission to the birthing area? You Selected:  fetal position and station Correct response:  contraction frequency and intensity Explanation: When admitting a multigravid client to the birthing area, the nurse needs to obtain information about the frequency, intensity, and duration of labor contractions; the time when the labor began; whether the membranes have ruptured; and the client’s estimated childbirth date. From this information, the nurse gets a quick overview of the client’s status and can then proceed to plan effective care. Although the time when the client last had food or fluids is important, this information can be obtained later because it is less influential in determining the initial plans for care. Although information about the fetal position is important, this information is less influential in determining the initial plans for care. The client’s ability to follow directions is important, but this information can be obtained later because it plays a less influential role in initial plans for care. Question 2 See full question The primary health care provider (HCP) prescribes whole blood replacement for a multigravid client with abruptio placentae. Before administering the intravenous blood product, the nurse should first: You Selected:  validate client information and the blood product with another nurse. Correct response:  validate client information and the blood product with another nurse. Explanation: When administering blood replacement therapy, extreme caution is needed. Before administering any blood product, the nurse should validate the client information and the blood product with another nurse to prevent administration of the wrong blood transfusion. Although baseline vital signs are necessary, she should initiate the infusion of blood slowly for the first 10 to 15 minutes. Then, if there is no evidence of a reaction, she should adjust the rate of infusion to ensure that the blood product is infused over 2 to 4 hours. The nurse can ask the client if she has ever had a reaction to a blood product, but a general question about allergies may not elicit the most complete response about any reactions to blood product administration. Blood transfusions are typically given with intravenous normal saline solution, not dextrose solutions. Question 3 See full question A client at 33 weeks' gestation is admitted in preterm labor. She is given betamethasone 12 mg IM q 24 hours × 2. What is the expected outcome of this drug therapy? You Selected:  The neonate will be born with mature lungs. Correct response:  The neonate will be born with mature lungs.