A nurse is admitting a client to the birthing unit who started having contractions an hour ago. The nurse determines the client is 80% effaced and 8 cm dilated.
What condition is the client at risk for?

Incompetent cervix

Hyperemesis gravidarum

Postpartum hemorrhage

Ectopic pregnancy

Answer and Explanation

The Correct Answer is C

Choice A rationale
An incompetent cervix is a condition that occurs when weak cervical tissue causes or contributes to premature birth or the loss of an otherwise healthy pregnancy. This condition is not directly related to the client’s current state of being 80% effaced and 8 cm dilated.
Choice B rationale
Hyperemesis gravidarum is a condition characterized by severe nausea, vomiting, weight loss, and electrolyte disturbance. Mild cases are treated with dietary changes, rest, and antacids.
More severe cases often require a stay in the hospital so that the mother can receive fluid and nutrition through an intravenous line. This condition is not directly related to the client’s current state of being 80% effaced and 8 cm dilated.
Choice C rationale
Postpartum hemorrhage is a condition that can occur due to a variety of factors, one of which is a rapid or prolonged labor, which can result in uterine atony. Given that the client is 80% effaced and 8 cm dilated, she is in active labor and could potentially be at risk for postpartum hemorrhage.
Choice D rationale

An ectopic pregnancy is a pregnancy in which the fertilized egg implants outside the uterus. The client is already in active labor, which means the pregnancy is not ectopic.

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Correct Answer is D

Explanation

Choice A rationale
Expecting two to four wet diapers every 24 hours is not accurate for a newborn. Newborns typically have six or more wet diapers per day. This indicates that the baby is getting enough milk.
Choice B rationale
Feeding the newborn 5 to 10 minutes per breast is not sufficient. It is recommended that newborns be breastfed for 15 to 20 minutes on each breast during each feeding. This ensures that the baby gets both the foremilk, which quenches the baby’s thirst, and the hindmilk, which provides the necessary nutrients and helps the baby feel full.
Choice C rationale

Giving the newborn 30 ml (1 oz) of water between feedings is not recommended. Newborns do not need additional water - breast milk or formula provides all the hydration they need. Giving a newborn extra water can lead to water intoxication, which is a serious condition.
Choice D rationale
Allowing the baby to feed at least every 3 hours is correct. Newborns should be fed on demand, typically every 2 to 3 hours. This ensures that the baby gets enough nutrition for growth and development.

A. Apply a moist, warm compress to the perineum. B. Administer methylergonovine 0.2 mg IM. C. Provide the client with a cool sitz bath. D. Apply povidone-iodine to the client’s perineum after she voids.

Correct Answer is C

Explanation

Choice A rationale
Applying a moist, warm compress to the perineum is not the recommended care for a client with a fourth-degree laceration of the perineum 12 hr postpartum.
Choice B rationale

Administering methylergonovine 0.2 mg IM is not the recommended care for a client with a fourth-degree laceration of the perineum 12 hr postpartum. Methylergonovine is a medication used to prevent or control bleeding of the uterus following childbirth or abortion.
Choice C rationale
Providing the client with a cool sitz bath is the correct action. A sitz bath can help to soothe the perineal area, reduce inflammation, and promote healing.
Choice D rationale
Applying povidone-iodine to the client’s perineum after she voids is not the recommended care for a client with a fourth-degree laceration of the perineum 12 hr postpartum. Povidone-iodine is an antiseptic used for skin disinfection before and after surgery.

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A nurse is admitting a client to the birthing unit who started having contractions an hour ago. The nurse determines the client is 80% effaced and 8 cm dilated. What condition is the client at risk for?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing discharge instructions to a client who is breastfeeding her newborn. Which of the following instructions should the nurse offer?

Correct Answer is D

Explanation

A nurse is caring for a client who is 12 hr postpartum and has a fourth-degree laceration of the perineum. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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A nurse is admitting a client to the birthing unit who started having contractions an hour ago. The nurse determines the client is 80% effaced and 8 cm dilated. What condition is the client at risk for?

A nurse is caring for a newborn immediately following birth. For which of the following reasons should the nurse delay the instillation of antibiotic ophthalmic ointment?

A nurse is admitting a client to the birthing unit who started having contractions an hour ago. The nurse determines the client is 80% effaced and 8 cm dilated.
What condition is the client at risk for?