A nurse is caring for a client in labor who is experiencing incomplete uterine relaxation between hypertonic contractions.

What adverse effect does the nurse recognize as a result of this contraction pattern?

Reduced fetal oxygen supply

Delayed cervical dilation

Prolonged labor

Increased maternal stress.

Answer and Explanation

The Correct Answer is B

Choice A rationale
While reduced fetal oxygen supply can occur with hypertonic contractions and inadequate uterine relaxation, it’s not the primary adverse effect. The main concern is the impact on the progress of labor.
Choice B rationale
This is the correct answer. Inadequate uterine relaxation between hypertonic contractions can delay cervical dilation, slowing the progress of labor.
Choice C rationale
Prolonged labor is not typically associated with hypertonic contractions and inadequate uterine relaxation. In fact, these conditions can lead to a more rapid labor.
Choice D rationale
Increased maternal stress can occur with any labor complication, but it’s not the primary adverse effect of hypertonic contractions and inadequate uterine relaxation.

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Correct Answer is B

Explanation

Choice A rationale
While it’s important to assess the level of parental anxiety related to the diagnosis, it’s not the immediate priority. The child’s physical health needs to be stabilized first.
Choice B rationale
This is the correct answer. Auscultating the rate and characteristics of the child’s heart sounds is the immediate priority. Acute rheumatic fever can lead to serious cardiac complications, so it’s crucial to monitor the child’s heart function closely.
Choice C rationale
While assessing the severity of joint pain is important in managing the child’s comfort, it’s not the immediate priority. The child’s heart function needs to be assessed first.
Choice D rationale
While assessing the client’s erythematous rash is part of the overall assessment of a child with acute rheumatic fever, it’s not the immediate priority. The child’s heart function needs to be assessed first.

A. Position the infant supine. B. Initiate contact precautions. C. Ensure a latex-free environment. D. Restrict visitors to immediate family members.

Correct Answer is C

Explanation

Choice A rationale
Positioning the infant supine is not the most appropriate intervention for an infant diagnosed with spina bifida who is scheduled for a surgical closure of the myelomeningocele sac. This position could put pressure on the sac and potentially lead to rupture or infection.
Choice B rationale
While contact precautions can be important in certain situations to prevent the spread of infection, they are not the primary intervention for a child with spina bifida undergoing surgery. The main concern is protecting the myelomeningocele sac from damage and infection.
Choice C rationale
Ensuring a latex-free environment is crucial for a child with spina bifida. Many children with spina bifida have a latex allergy, and exposure to latex can cause an allergic reaction. This can range from skin redness and itching to more serious symptoms such as wheezing and difficulty breathing.
Choice D rationale
Restricting visitors to immediate family members is not specifically related to the care of an infant with spina bifida. While limiting visitors can help reduce the risk of infection, it is not the primary concern in this case.

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A nurse is caring for a client in labor who is experiencing incomplete uterine relaxation between hypertonic contractions. What adverse effect does the nurse recognize as a result of this contraction pattern?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is attending to an 8-year-old child diagnosed with acute rheumatic fever. What should be the nurse’s immediate priority assessment after admission?

Correct Answer is B

Explanation

A nurse is formulating a care plan for an infant diagnosed with spina bifida who is scheduled for a surgical closure of the myelomeningocele sac. Which of the following interventions should be incorporated into the care plan?

Correct Answer is C

Explanation

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A nurse is caring for a client in labor who is experiencing incomplete uterine relaxation between hypertonic contractions.

What adverse effect does the nurse recognize as a result of this contraction pattern?