Questions and Answers with Rationale
A client wants to abort her pregnancy after 4 months of gestation. Which oral medication would be given to the client?
1 Oxytocin
2 Misoprostol
3 Indomethacin
4 Dinoprostone
Rationale: Misoprostol is an oral drug used to induce an abortion. Oxytocin is available as an injection; it is used to induce labor at or near full-term gestation. Indomethacin is used to maintain a pregnancy during preterm labor. Dinoprostone is used to induce an abortion; it is available only for vaginal use.
A client asks the nurse what she should do if she forgets to take the pill one day. How should the nurse respond?
1. "Take your pills as instructed."
2. "Call your practitioner immediately."
3. "Continue as usual and there should not be a problem."
4. "On the next day take one pill in the morning and one before bedtime."
1. "Take your pills as instructed."
2. "Call your practitioner immediately."
3. "Continue as usual and there should not be a problem."
4. "On the next day take one pill in the morning and one before bedtime."
Rationale: The client should make up for the missed pill by taking two the next day; taking one in the morning and one in the evening lessens the chance of the client becoming nauseated.
A client is receiving an intravenous piggyback infusion of oxytocin to augment labor. The nurse identifies three contractions lasting 80 to 90 seconds less than 2 minutes apart. A specific protocol is followed in response to this observation. List in order of priority the nursing actions that should be taken.
Correct Answer
1. Stop the piggyback infusion.
2. Check the fetal heart rate (FHR).
3. Determine whether the contractions have diminished.
4. Notify the primary healthcare provider.
5. Administer oxygen by way of facemask
6. Document the responses of the client and fetus
Rationale: When tetanic contractions occur, the nurse should first stop the oxytocin infusion; this should relax the uterus and prevent uterine tetany and rupture.
The FHR should be checked to determine the effect of the tetanic contractions on the fetus.
After the FHR has been assessed, th e maternal response to the interruption of the infusion should be assessed.
Once these measures have been implemented, the primary care giver should be notified.
Fetal well-being will improve when oxygen is administered.
After emergency measures have been taken, the client’s and fetus’s responses should be documented.
A nurse is planning care with a client for the recovery period after a laparoscopic hysterectomy and bilateral salpingo-oophorectomy. What should be included in the information regarding the changes that the client should expect after surgery?
Rationale: When bilateral oophorectomy is performed, both ovaries are excised, eliminating ovarian hormones and initiating menopause. Although depression may occur, it is not expected; if it does occur, intervention is required. There is no physiologic reason for weight gain after hysterectomy. Urine retention is not an expected concern, because a urine retention catheter is inserted before surgery and left in place generally for 24 hours, regardless of the type of hysterectomy (e.g., laparoscopic, abdominal, vaginal).
During labor an internal fetal monitor is applied. Which fetal heart rate (FHR) should most concern the nurse?
1 One that does not slow during contractions
2 One that ranges from 130 to 140 beats/min
3 One that drops to 110 beats/min during a contraction
4 One that returns to baseline after a contraction ends
1 One that does not slow during contractions
2 One that ranges from 130 to 140 beats/min
3 One that drops to 110 beats/min during a contraction
4 One that returns to baseline after a contraction ends
Rationale: A return of the FHR to baseline after a contraction ends is called a late deceleration; it begins after the contraction has started, the lowest point of the deceleration occurs after the peak of the contraction, and the deceleration usually does not return to baseline until after the contraction ends (late recovery). Late decelerations, which are caused by uteroplacental insufficiency, are a sign of a compromised fetus. The FHR does not always drop with a contraction. Beat-to-beat variability indicates a fetus with a healthy nervous system and does not warrant concern. A decrease in fetal heart rate to 110 beats/min during a contraction, known as an early deceleration, is the result of fetal head compression during a contraction; the FHR returns to baseline at the same time that the contraction ends.
The nurse is caring for a client who is in the first stage of labor. The fetal heart rate monitor displays an irregular baseline that was in the 150s and is now in the 130s with variability. What is the priority nursing intervention?
1 Administering oxygen
2 Notifying the primary healthcare provider
3 Changing the client’s position
4 Continuing to monitor the client
Rationale: This is an expected occurrence caused by the interplay of the sympathetic and parasympathetic nervous systems. Because this is an expected response, there is no need to administer oxygen, notify the primary healthcare provider, or change the client’s position.
0
1759