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A client in active labor becomes very uncomfortable and asks a nurse for pain
medication. Nalbuphine (Nubain) is prescribed. How does this medication relieve pain?
- ANSWER- By acting on opioid receptors to reduce pain
-Nalbuphine (Nubain) is classified as an opioid analgesic and is effective in relieving
pain; it induces little or no newborn respiratory depression. Nalbuphine does not induce
amnesia, act as an anesthetic, or induce sleep.
A client is admitted to the birthing unit in active labor. Amniotomy is performed by the
health care provider. What physiological change does the nurse expect to occur after
the procedure? - ANSWER- Progressive dilation and effacement
A nurse is teaching a primigravida about how she can identify the onset of labor. What
clinical indicator of labor would necessitate the client to call her health care provider? -
ANSWER- Rupture of membranes or contractions 5 minutes apart
A woman who has just delivered an infant asks to take the placenta home with her and
her new baby on discharge. What is the most appropriate response? - ANSWER- "I
need to check the hospital protocol for our policy on that practice."
A 36-year-old multigravida who is at 14 weeks' gestation is scheduled for an
αfetoprotein test. She asks the nurse, "What does this test do?" The nurse bases the
response on the knowledge that this test can reveal: - ANSWER- Neural tube defects
During a client's first visit to the prenatal clinic, a nurse discusses a pregnancy diet. The
client states that her mother told her that she should restrict her salt intake. What is the
nurse's best response? - ANSWER- "Because you need salt to maintain body water
Balance; it is not restricted. Just eat a well-balanced diet."
A client who is at 10 weeks' gestation returns for her second prenatal visit. She asks
why she has to urinate so often. The nurse tells her that urinary frequency in the first
trimester is: - ANSWER- Influenced by the enlarging uterus, which is still within the
pelvis
The nurse is caring for a client who has just received epidural anesthesia. Which finding
would be of most concern? - ANSWER- Hypotension
,A nurse is preparing to counsel a client whose two previous pregnancies were
uneventful, ending in term vaginal births of healthy children. What should the nurse
consider about multiparas with previous uneventful pregnancies before beginning
prenatal counseling? - ANSWER- Each pregnancy is a unique experience that is
stressful despite multiparity.
The four essential components of labor are powers, passageway, passenger, and
psyche. Passageway refers to the bony pelvis. What type of pelvis is considered the
most favorable for a vaginal delivery? - ANSWER- Gynecoid
-A gynecoid pelvis is considered most favorable for a vaginal birth because the inlet
allows the fetus room to pass. The gynecoid pelvis is considered the typical female
pelvis. An android pelvis, which has a heart shape, is considered a male pelvis. The
fetus often gets stuck. The anthropoid pelvis is elongated, with a roomy anterior
posterior dimension and a narrower transverse diameter than the gynecoid pelvis.
Although delivery is possible with this type of pelvis, it is less likely to be successful.
The platypelloid pelvis is flat, with a compressed oval shape as the middle opening,
instead of an open circle like the gynecoid pelvis. This is a rare type of pelvis.
A nurse is caring for a client during the transition phase of labor. The nurse determines
that the client has entered the second stage of labor when: - ANSWER- The client
reports that she feels the urge to move her bowels
A client in active labor is admitted to the birthing room. A vaginal examination reveals
that the cervix is dilated 6 to 7 cm. In light of this finding, the nurse expects that the: -
ANSWER- Client's contractions will become longer and more frequent
A woman at 36 weeks' gestation is admitted to the hospital to receive a tocolytic
medication in an attempt to stop labor. In addition, betamethasone (Celestone) is
prescribed to enhance fetal lung maturity. The prescription reads: "Administer
betamethasone 12 mg IM daily for 3 days." The betamethasone comes in a vial labeled
"6 mg/mL." How many milliliters should the nurse administer each day? Record your
ANSWER using a whole number. ____ mL - ANSWER- 2
A pregnant client's blood test reveals an increased alpha-fetoprotein (AFP) level. What
condition does the nurse suspect that this result indicates? - ANSWER- Neural tube
defect
How does the nurse know that a client at 40 weeks' gestation is experiencing true
labor? - ANSWER- Cervical dilation
During the examination of a client in labor, the cervix is determined to be dilated 4 cm.
, What stage of labor does the nurse record? - ANSWER- First
-The first stage of labor is from zero cervical dilation to full cervical dilation (10 cm). The
second stage is from full cervical dilation to delivery. The prodromal stage is before
cervical dilation begins. The transitional phase is first stage of labor, from 8 cm of
dilation to 10 cm of dilation
During a counseling discussion of nutrition, a nurse explains to a pregnant client that
she will need additional calcium during pregnancy and that the best source is milk. The
client states, "I never drink milk or eat milk products. They turn my stomach." What is
the nurse's best reply? - ANSWER- "Your practitioner can prescribe calcium
supplements."
A client in active labor starts screaming, "The baby is coming! Do something!" What is
the first nursing action? - ANSWER- Checking the perineal area for the presenting part
A client at 22 weeks' gestation asks the nurse how to prevent back pain as her
pregnancy progresses. What does the nurse suggest that she wear? - ANSWER-
Lowheeled shoes
-Low-heeled supportive shoes help maintain the body's center of gravity over the hips,
limiting arching of the back that compensates for the increased weight in the abdominal
area.
A 16-year-old adolescent at 24 weeks' gestation visits the prenatal clinic for the first
time. After the physical examination she tells the nurse, "I can't believe how big I am.
Will I get much bigger?" What information about adolescent growth and development
does the nurse need to know before responding? - ANSWER- Body image is very
important to adolescents, so pregnant teenagers are concerned about body size.
After a client gives birth, what physiological occurrence indicates to the nurse that the
placenta is beginning to separate from the uterus and is ready to be expelled? -
ANSWER- Appearance of a sudden gush of blood
During the postpartum period a client tells a nurse that she has been having leg cramps.
Which foods should the nurse encourage the client to eat? - ANSWER- Cheese and
broccoli
What actions are part of nursing care during the fourth stage of labor for the client with a
fourth-degree laceration? (Select all that apply.) - ANSWER- 1 Pain management with
oral analgesics
3 Assessment of the site every 15 minutes
5 Application of an ice pack for 20-minute intervals