Nursing Elites

1. A client in active labor has 7 cm of cervical dilation, 100% effacement, and the fetus at 1+ station. The client's amniotic membranes are intact, but she suddenly expresses the need to push. What should the nurse do?

• A. Assist the client into a comfortable position.
• B. Observe the perineum for signs of crowning.
• C. Have the client pant during the next contractions.
• D. Help the client to the bathroom to void.

Correct answer: C

Rationale: Having the client pant during contractions is crucial to prevent premature pushing, particularly when the cervix is not fully dilated. Premature pushing can lead to cervical swelling and may impede the progress of labor. It is important to allow the cervix to fully dilate before active pushing to prevent complications. Assisting the client into a comfortable position (Choice A) may not address the urge to push and can lead to premature pushing. Observing the perineum for signs of crowning (Choice B) is important but does not address the immediate need to prevent premature pushing. Helping the client to the bathroom to void (Choice D) does not address the urge to push and may not be appropriate at this stage of labor.

2. A client in active labor at 39 weeks of gestation is receiving continuous IV oxytocin and has early decelerations in the FHR on the monitor tracing. What action should the nurse take?

• A. Discontinue the oxytocin infusion.
• B. Continue monitoring the client.
• C. Request that the provider assess the client.
• D. Increase the infusion rate of the maintenance IV fluid.

Correct answer: B

Rationale: Early decelerations in the FHR are benign and are typically caused by fetal head compression during contractions. In this case, with the client at 39 weeks of gestation and on oxytocin, it is important for the nurse to continue monitoring the client. Early decelerations do not require intervention as they are a normal response to certain stimuli and do not indicate fetal distress. Discontinuing the oxytocin infusion (Choice A) is not necessary as early decelerations are not related to oxytocin administration. Requesting the provider to assess the client (Choice C) is not needed for early decelerations as they are a normal finding. Increasing the infusion rate of the maintenance IV fluid (Choice D) is not indicated and would not address the early decelerations. Therefore, the appropriate action is to continue monitoring the client and reassess as needed.

3. A nurse on the labor and delivery unit is caring for a client who is having a difficult, prolonged labor with severe backache. Which of the following contributing causes should the nurse identify?

• A. Fetal attitude is in general flexion.
• B. Fetal lie is longitudinal.
• C. Maternal pelvis is gynecoid.
• D. Fetal position is persistent occiput posterior.

Correct answer: D

Rationale: The correct answer is D. In a persistent occiput posterior position, the baby's head presses against the mother's spine, causing prolonged labor and severe backache. This position can lead to difficulties in labor progress and increase discomfort for the mother. Choices A, B, and C are incorrect as they do not directly relate to the client's difficult, prolonged labor with severe backache. Fetal attitude, fetal lie, and maternal pelvis type may affect labor, but in this scenario, the persistent occiput posterior fetal position is the primary contributing cause for the client's symptoms.

4. A client at 42 weeks of gestation is having an ultrasound. For which of the following conditions should the nurse prepare for an amnioinfusion? (Select all that apply)

• A. Oligohydramnios
• B. Hydramnios
• C. Fetal cord compression
• D. Polyhydramnios

Correct answer: A

Rationale: In this scenario, the correct answer is "Oligohydramnios". Oligohydramnios, which refers to low amniotic fluid volume, may necessitate amnioinfusion to address the deficiency. Fetal cord compression is another indication for amnioinfusion as it can help alleviate pressure on the umbilical cord. Hydramnios or polyhydramnios, conversely, involve an excess of amniotic fluid and do not typically require amnioinfusion. Therefore, choices B, C, and D are incorrect in this context.

5. A client has severe preeclampsia and is receiving magnesium sulfate IV. Which of the following findings should the nurse identify and report as signs of magnesium sulfate toxicity? (Select all that apply)

• A. Respirations less than 12/min
• B. Urinary output less than 25 mL/hr
• C. Decreased level of consciousness
• D. All of the above

Correct answer: D

Rationale: Signs of magnesium sulfate toxicity include respirations less than 12/min, urinary output less than 25 mL/hr, and decreased level of consciousness. These signs indicate potential overdose of magnesium sulfate and require immediate attention to prevent further complications. Reporting these signs promptly is crucial to ensure the client's safety and well-being. Choice D, 'All of the above,' is the correct answer as all the listed findings are indicative of magnesium sulfate toxicity. Choices A, B, and C individually represent different signs of toxicity, making them incorrect on their own. Therefore, the nurse should be vigilant in identifying and reporting all these signs to prevent adverse outcomes.

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