Reproduction intrepartum prepu Question 1 See full question While a 31-year-old multigravida at 39 weeks’ gestation in active labor is being admitted,
... [Show More] her amniotic membranes rupture spontaneou sly. The client’s cervix is 5 cm dilated, the presenting part is at 0 station, and the electronic fetal heart rate pattern is reassuring. What should the nurse do first? You Selected: • Prepare the client for imminent birth. Correct response: • Note the color, amount, and odor of the amniotic fluid. Explanation: The nurse’s first action when membranes rupture spontaneously is to check the odor, consistency, and volume of the amniotic fluid. Because the fetal head is engaged and at 0 station, there is little likelihood of cord prolapse. However, when the fetal head is not engaged, checking for cord prolapse would be the priority when the membranes rupture spontaneously. After rupture of the membranes, vaginal examinations should be kept to a minimum to decrease the chance of infection. Although auscultating the client’s blood pressure is important, it is not the priority following spontaneous rupture of membranes. Birth is not imminent if the client is 5 cm dilated. However, multigravid clients may progress quickly in labor, especially after rupture of the membranes. Remediation: Question 2 See full question What interval should the nurse use when assessing the frequency of contractions of a multiparous client in active labor admitted to the birthing area? You Selected: • beginning of one contraction to the beginning of the next contraction Correct response: • beginning of one contraction to the beginning of the next contraction Explanation: To assess the frequency of the client’s contractions, the nurse should assess the interval from the beginning of one contraction to the beginning of the next contraction. The duration of a contraction is the interval between the beginning and the end of a contraction. The acme identifies the peak of a contraction. Remediation: Question 3 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: • ask the client if she has ever had any allergies. 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. Remediation: Question 4 See full question A client at 36 weeks' gestation is admitted in preterm labor with a temperature of 101.2° F (38.4° C). She reports a steady dripping from the vaginal area and examination indicates that she's leaking amniotic fluid. A nurse realizes the probable cause of her fever is: You Selected: • a normal response to labor. Correct response: • intrauterine infection. Explanation: Premature membrane rupture creates an open port for intrauterine infection, indicated by an elevated temperature. The client doesn't exhibit signs or symptoms that would indicate the flu. Fever and premature rupture of membranes aren't normal findings in labor. There is no indication that the thermometer is malfunctioning. Remediation: Question 5 See full question After instructing the client in techniques of pushing to use during the second stage of labor, the nurse determines that the client needs further instructions when she says she will need to do which action? You Selected: • hold her breath throughout the length of the contraction Correct response: • hold her breath throughout the length of the contraction Explanation: The client should use exhale breathing (inhaling several deep breaths, holding the breath for 5 to 6 seconds, and exhaling slowly every 5 to 6 seconds through pursed lips while continuing to hold the breath) while pushing to avoid the adverse physiologic effects of the Valsalva maneuver, occurring with prolonged breath holding during pushing. The Valsalva maneuver also can be avoided by exhaling continuously while pushing. Semi-Fowler’s position enhances the effectiveness of the abdominal muscle efforts during pushing, but the client can assume a squatting or side-lying position if desired. The client should flex her thighs onto her abdomen before bearing down to decrease the length of the vagina and increase the pelvic diameter. The client should exert downward pressure as if she were having a bowel movement while pushing. Remediation [Show Less]