A term multigravida, who is receiving oxytocin for labor augmentation is requesting pain
medication. Review of the client’s record indicates that she
... [Show More] was medicated 30 minutes ago with
butorphanol tartare 2 mg & promethazine 25 mg IV push. Vaginal examination reveals that the
client’s cervical dilation is 3 cm, 70% effaced, and at a 0 station. Which action should the nurse
implement?
A. Instruct the client to use deep breathing during a contraction
B. Notify the healthcare provider
C. Discontinue the oxytocin infusion
D. Medicate the client with an additional 1 mg of butorphanol tartrate IV push
When preparing to assist the healthcare provider with a vaginal examination to assess a client’s
cervical dilation during labor, which equipment should the nurse assemble?
A. Sterile glove & sterile speculum
B. Sterile glove & speculum
C. Sterile glove & lubricant
D. Sterile speculum & lubricant
Following a vaginal delivery, the nurse places the neonate under the radiant warmer, provides
naso-oropharyneal suction, and dries the neonate’s skin to elicit spontaneous respirations. The
newborn’s heart rate is 100 beats/minute & remains apneic when the nurse flicks the soles of
the feet. Which action should the nurse implement next?
A. Assist neonatologist with intubation
B. Provide positive pressure ventilation
C. Start IV infusion in a scalp vein
D. Give blow-by oxygen via cannula
The nurse performs a routine assessment on a 12-hour-old infant. Which finding requires
intervention?
A. No voiding or stooling since birth
B. Crying for more than 10 minutes
C. Respiratory rate of 73 breaths/minute
D. Acrocyanosis with hands & feet cool to touch
The nurse receives change-of-shift report for four newborns. The nurse should monitor closely
which newborn for an increased risk for developing neonatal sepsis
A. Birth weight of 2.75 kg
B. Reported prolonged rupture of membranes
C. Delivered by scheduled Cesarean section
D. Ballard score of 36-weeks-gestation [Show Less]