Nokea
A client at 34 weeks' gestation is diagnosed with polyhydramnios. What is the nurse's priority assessment?
- A. Monitor maternal blood pressure.
- B. Assess for signs of preterm labor.
- C. Check for signs of infection.
- D. Evaluate for fetal heart rate changes.
Correct Answer: B
Rationale: Polyhydramnios increases the risk of preterm labor due to uterine overdistension, requiring close monitoring.
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The laboring person asks the nurse to review the birth plan. What item is on a typical birth plan?
- A. where the patient will be staying after birth
- B. who will be watching their other children
- C. what position they want to birth in
- D. how they will time contractions
Correct Answer: C
Rationale: Birth plans often include preferences for birthing positions to promote comfort and effectiveness.
A nurse is planning care for a client who is pregnant and has HIV. Which of the following actions should the nurse include in the plan of care?
- A. Instruct the client to stop taking the antiretroviral medication at 32 weeks of gestation.
- B. Use a fetal scalp electrode during labor and delivery.
- C. Administer a pneumococcal immunization to the newborn within 4 hr. following birth.
- D. Bathe the newborn before initiating skin-to-skin contact
Correct Answer: C
Rationale: Administering a pneumococcal immunization to the newborn within 4 hours following birth is a crucial action to include in the plan of care for a pregnant client with HIV. Infants born to HIV-positive mothers are at higher risk for infections, including pneumococcal disease. Administering a pneumococcal vaccine shortly after birth helps protect the newborn from this serious infection. It is important to follow established guidelines for immunizations in newborns of HIV-positive mothers to optimize the infant's health outcomes.
What does the nurse say about labor beginning to the laboring person who has studied Lamaze?
- A. We should walk in the hallways to get your labor started.â€
- B. Let's turn the lights down and get you into a comfortable position with your partner next to you.â€
- C. I bet you are ready for the Pitocin to get started to get your baby here.â€
- D. Early labor is the best time for you to come to the hospital.â€
Correct Answer: B
Rationale: Lamaze emphasizes comfort and partner support, aligning with creating a calm environment for labor.
The nurse is assessing a client at 20 weeks' gestation who reports leg cramps. What is the most likely cause?
- A. Dehydration.
- B. Calcium deficiency.
- C. Increased blood volume.
- D. Compression of pelvic nerves.
Correct Answer: D
Rationale: Compression of pelvic nerves from the growing uterus can cause leg cramps during pregnancy.
What is the most important teaching for a mother of a preterm infant in an incubator?
- A. Emphasize the importance of frequent temperature checks
- B. Demonstrate proper hand hygiene practices
- C. Educate the mother on kangaroo care
- D. Explain the importance of reduced stimulation
Correct Answer: C
Rationale: Educating about kangaroo care promotes bonding and stabilizes the infant's vital signs.