A nurse is caring for a client who has prolonged labor and is at risk for infection.

Which of the following actions should the nurse take to reduce this risk? (Select all that apply.)

Perform frequent vaginal exams.

Change perineal pads every 2 hours.

Encourage oral fluid intake.

Administer IV antibiotics as prescribed.

Use sterile gloves when providing perineal care.

Answer and Explanation

Correct Answer : B,C,D,E

These actions can help reduce the risk of infection for the client who has prolonged labor.

• Choice B is correct because changing perineal pads every 2 hours can prevent bacterial growth and contamination of the genital tract.

• Choice C is correct because encouraging oral fluid intake can help maintain hydration and blood volume, which can improve uterine perfusion and prevent maternal and fetal acidosis.

• Choice D is correct because administering IV antibiotics as prescribed can prevent or treat maternal peripartum infections, which are among the leading causes of maternal mortality worldwide.

• Choice E is correct because using sterile gloves when providing perineal care can prevent introducing pathogens into the genital tract.

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Correct Answer is A

Explanation

Caput succedaneum is a swelling of the scalp that can occur after vacuum extraction delivery.It is caused by the pressure of the suction cup on the baby’s head and usually resolves within a few days.

A. Placental abruption B. Umbilical cord prolapse C. Ruptured vasa previa D. Bleeding from the cervix.

Correct Answer is C

Explanation

This is a condition where fetal blood vessels that run through the membranes rupture and bleed.

The bleeding is from the fetus, not the mother, and can cause fetal hypoxia and death.

The FHR deceleration indicates fetal distress.

The uterus is soft because there is no uterine bleeding or contraction.

Normal ranges for FHR are 110 to 160 beats per minute.

Normal ranges for uterine contraction frequency are 2 to 5 contractions in 10 minutes.

Normal ranges for uterine contraction duration are 45 to 80 seconds.

Normal ranges for uterine contraction intensity are mild to moderate to palpation

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A nurse is caring for a client who has prolonged labor and is at risk for infection. Which of the following actions should the nurse take to reduce this risk? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting a client who has prolonged and obstructed labor to deliver by vacuum extraction. Which of the following complications should the nurse monitor for in the newborn?

Correct Answer is A

Explanation

A gush of blood is noted with the rupture of membranes. On palpation, the uterus is soft (i.e., relaxed) and the patient is not reporting any pain. An FHR deceleration down to 90 bpm is noted. What does the nurse suspect has happened?

Correct Answer is C

Explanation

A nurse is reviewing the risk factors for uterine rupture with a group of nursing students. Which of the following risk factors should the nurse include? (Select all that apply.)

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A nurse is caring for a client who has prolonged labor and is at risk for infection. Which of the following actions should the nurse take to reduce this risk? (Select all that apply.)

A nurse is evaluating a client who has prolonged labor and suspects uterine rupture. Which of the following findings should alert the nurse to this complication?

A nurse is assessing a client who is in labor and notes that the fetal head is visible at the vaginal opening but does not advance with pushing. The nurse should identify this finding as which of the following?

A nurse is caring for a client who has prolonged labor and is at risk for infection.

Which of the following actions should the nurse take to reduce this risk? (Select all that apply.)