Nursing Elites

1. A client whose labor is being augmented with an oxytocin (Pitocin) infusion requests an epidural for pain control. Findings of the last vaginal exam, performed 1 hour ago, were 3 cm cervical dilation, 60% effacement, and a -2 station. What action should the nurse implement first?

• A. Decrease the oxytocin infusion rate
• B. Determine current cervical dilation
• C. Request placement of the epidural
• D. Give a bolus of intravenous fluids

Correct answer: D

Rationale: In a client receiving an oxytocin infusion who requests an epidural, it is crucial to give a bolus of intravenous fluids first. This action helps prevent hypotension, a common side effect of epidural anesthesia, before the placement of the epidural. Maintaining adequate hydration is essential to support maternal blood pressure stability during the procedure.

2. A multiparous client with active herpes lesions is admitted to the unit with spontaneous rupture of membranes. Which action should the nurse take?

• A. Obtain blood culture.
• B. Administer penicillin.
• C. Cover lesion with a dressing.
• D. Prepare her for cesarean section.

Correct answer: D

Rationale: Active herpes lesions at the time of delivery increase the risk of neonatal transmission. The most appropriate action in this scenario is to prepare the client for a cesarean section. A cesarean section is often recommended to reduce the risk of neonatal transmission of herpes simplex virus during delivery, especially when active lesions are present. This intervention helps minimize direct contact between the newborn and the infected genital tract secretions, thereby decreasing the risk of transmission.

3. When should the LPN/LVN encourage the laboring client to begin pushing?

• A. When there is only an anterior or posterior lip of the cervix left.
• B. When the client describes the need to have a bowel movement.
• C. When the cervix is completely dilated.
• D. When the cervix is completely effaced.

Correct answer: C

Rationale: The LPN/LVN should encourage the laboring client to begin pushing when the cervix is completely dilated to 10 centimeters. Pushing before full dilation can lead to cervical injury and ineffective labor progress. By waiting for complete dilation, the client can push effectively, aiding in the descent of the baby through the birth canal. Choices A, B, and D are incorrect because pushing before complete dilation can be harmful and may not effectively help in the descent of the baby. The presence of an anterior or posterior lip of the cervix, the urge to have a bowel movement, or complete effacement of the cervix are not indicators for the initiation of pushing during labor.

4. While caring for a laboring client on continuous fetal monitoring, the nurse notes a fetal heart rate pattern that falls and rises abruptly with a 'V' shaped appearance. What action should the nurse take first?

• A. Change the maternal position.
• B. Administer oxygen at 10 L by mask.
• C. Prepare for a potential cesarean.
• D. Allow the client to begin pushing.

Correct answer: A

Rationale: In cases of fetal heart rate patterns showing abrupt falls and rises with a 'V' shaped appearance, it indicates possible cord compression. Changing the maternal position, such as moving the mother onto her side, can relieve the pressure off the cord and help improve fetal oxygenation, making it the priority intervention to address the decelerations.

5. The client delivered hours ago and has a boggy uterus displaced above and to the right of the umbilicus. What action should the nurse take?

• A. Inspect the perineal pad.
• B. Encourage voiding.
• C. Monitor vital signs.
• D. Notify the healthcare provider.

Correct answer: B

Rationale: A boggy uterus that is displaced above and to the right of the umbilicus may indicate a full bladder, which can impede uterine contraction and lead to hemorrhage. Encouraging the client to void helps relieve pressure on the uterus, promoting better contraction and preventing postpartum hemorrhage.

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