A 42-week gestational client is receiving an intravenous infusion of oxytocin (Pitocin) to augment early labor. The nurse should discontinue the oxytocin infusion for which pattern of contractions? A. Transition labor with contractions every 2 minutes, lasting 90 seconds each. B. Early labor with contractions every 5 minutes, lasting 40 seconds each. C. Active labor with contractions every 31 minutes, lasting 60 seconds each. D. Active labor with contractions every 2 to 3 minutes, lasting 70 to 80 seconds each. - ANS-A Transition labor with contractions every 2 minutes, lasting 90 seconds each. Contraction pattern describes hyperstimulation and an inadequate resting time between contractions to allow for placental perfusion. A client in active labor is admitted with preeclampsia. Which assessment finding is most significant in planning this client's care? A. Patellar reflex 4+. B. Blood pressure 158/80. C. Four-hour urine output 240 ml. D. Respiration 12/minute. - ANS-A 4+ reflex in a client with pregnancy-induced hypertension indicates hyperreflexia, which is an indication of an impending seizure. The nurse is preparing a client with a term pregnancy who is in active labor for an amniotomy. What equipment should the nurse have available at the client's bedside? (Select all that apply.) A. Litmus paper. B. Fetal scalp electrode. C. A sterile glove. D. An amniotic hook. E. Sterile vaginal speculum. F. A Doppler. - ANS-C, D, F A single sterile glove, an amniotic hook, and Doppler to check fetal heart tones are the necessary equipment for performing an amniotomy. In developing a teaching plan for expectant parents, the nurse plans to include information about when the parents can expect the infant's fontanels to close. The nurse bases the explanation on knowledge that for the normal newborn, the A. anterior fontanel closes at 2 to 4 months and the posterior by the end of the first week. B. anterior fontanel closes at 5 to 7 months and the posterior by the end of the second week. C. anterior fontanel closes at 8 to 11 months and the posterior by the end of the first month. D. anterior fontanel closes at 12 to 18 months and the posterior by the end of the second month. - ANS-D anterior fontanel closes at 12 to 18 months and the posterior by the end of the second month. In the normal infant the anterior fontanel closes at 12 to 18 months of age and the posterior fontanel by the end of the second month (D). Which assessment finding should the nursery nurse report to the pediatric healthcare provider? A. Blood glucose level of 45 mg/dl. B. Blood pressure of 82/45 mmHg. C. Non-bulging anterior fontanel. D. Central cyanosis when crying. - ANS-D An infant who demonstrates central cyanosis when crying is manifesting poor adaptation to extrauterine life which should be reported to the healthcare provider for determination of a possible underlying cardiovascular problem. The nurse is assessing a client who is having a non-stress test (NST) at 41-weeks gestation. The nurse determines that the client is not having contractions, the fetal heart rate (FHR) baseline is 144 bpm, and no FHR accelerations are occurring. What action should the nurse take? A. Check the client for urinary bladder distention. B. Notify the healthcare provider of the nonreactive results. C. Have the mother stimulate the fetus to move. D. Ask the client if she has felt any fetal movement. - ANS-D Ask the client if she has felt any fetal movement. A full-term infant is admitted to the newborn nursery and, after careful assessment, the nurse suspects that the infant may have an esophageal atresia. Which symptoms is this newborn likely to have exhibited? A. Choking, coughing, and cyanosis. B. Projectile vomiting and cyanosis. C. Apneic spells and grunting. D. Scaphoid abdomen and anorexia. - ANS-A Choking, coughing, and cyanosis. the "3 Cs" of esophageal atresia caused by the overflow of secretions into the trachea. A woman who had a miscarriage 6 months ago becomes pregnant. Which instruction is most important for the nurse to provide this client? A. Elevate lower legs while resting. B. Increase caloric intake by 200 to 300 calories per day. C. Increase water intake to 8 full glasses per day. D. Take prescribed multivitamin and mineral supplements. - ANS-D A client who has had a spontaneous abortion or still birth in the last 1½ years should take multivitamin and mineral supplements and maintain a balanced diet because the previous pregnancy may have left her nutritionally depleted.