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A client with an obstetrical history of G1 P0000 received dinoprostone for cervical ripening 8 hours ago.
The Bishop score at that time was 4. The Bishop score is now 10. Which of the following actions by the nurse is appropriate?

A.

Report abnormal findings to the obstetrician.

B.

Place client on her side.

C.

Monitor for onset of labor.

D.

Perform nitrazine analysis of amniotic fluid.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Reporting abnormal findings to the obstetrician is unnecessary because an increase in the Bishop score from 4 to 10 indicates successful cervical ripening and readiness for labor

induction.

 

Choice B rationale

Placing the client on her side is not directly related to the assessment of cervical ripening or the Bishop score. It may be considered for comfort during labor.

 

Choice C rationale

Monitoring for the onset of labor is appropriate since the increase in the Bishop score to 10 suggests that the cervix is favorable for labor. Continuous monitoring is essential to detect

the onset and progression of labor.

 

Choice D rationale

Performing nitrazine analysis of amniotic fluid is not relevant to the assessment of cervical ripening or the Bishop score. This test is typically used to confirm the presence of amniotic

fluid in cases of suspected rupture of membranes.


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View Related questions

Correct Answer is B

Explanation

Choice A rationale

Decreased muscle tone is not typically associated with neonatal abstinence syndrome (NAS). Instead, NAS often presents with hypertonia or increased muscle tone due to

withdrawal symptoms.

Choice B rationale

A continuous high-pitched cry is a hallmark sign of NAS, indicating the newborn is experiencing withdrawal and discomfort. This symptom results from the overstimulation of the

central nervous system.

Choice C rationale

Newborns with NAS often have difficulty sleeping and may sleep for shorter periods due to irritability and discomfort. Prolonged sleep after feeding is not characteristic of NAS.

Choice D rationale

Tremors in newborns with NAS are usually pronounced and continuous, not just when disturbed. These tremors are a result of withdrawal effects on the nervous system.

Correct Answer is A

Explanation

Choice A rationale

Postpartum psychosis poses significant risks to both the mother and her infant. The mother may have impaired judgment, hallucinations, or delusions, making it unsafe for her to be

left alone with her baby.

Choice B rationale

Symptoms of postpartum psychosis can persist for several weeks to months without appropriate treatment. Immediate and ongoing intervention is crucial to manage the condition.

Choice C rationale

Clinical response to medications for postpartum psychosis can vary, but with proper treatment, many clients show significant improvement. It is not accurate to state that the

response is usually poor.

Choice D rationale

While monitoring vitals may be part of overall care, it is not the most critical teaching point. Ensuring the mother is never left alone with her infant is essential to prevent potential

harm.

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