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A client at 40-weeks gestation presents to the obstetrical floor and indicates that the amniotic membranes ruptured spontaneously at home. She is in active labor, and feels the need to bear down and push. Which information is most important for the nurse to obtain?
- A. Estimated amount of fluid.
- B. Color and consistency of fluid.
- C. Time the membranes ruptured
- D. Any odor noted when membranes ruptured
Correct Answer: C
Rationale: The time of membrane rupture is critical to assess the risk of infection, which increases with prolonged rupture, especially in active labor.
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A client who is 32 weeks gestation comes to the women's health clinic and reports nausea and vomiting. On examination, the nurse notes that the client has an elevated blood pressure. Which action should the nurse implement next?
- A. Inspect the client's face for edema
- B. Ascertain the frequency of headaches
- C. Evaluate for history of cluster headaches
- D. Observe and time client's contractions
Correct Answer: A
Rationale: Elevated blood pressure at 32 weeks may suggest preeclampsia. Inspecting for facial edema is a priority to assess for fluid retention, a key sign of this condition.
A 25-year-old client who had a severe postpartum hemorrhage following the vaginal birth of twins is transferred to the postpartum unit. The nurse knows that assessment for what complication has the highest priority for this client?
- A. Placenta accreta
- B. Hard, painful uterine afterpains.
- C. Postpartum psychosis.
- D. Disseminated intravascular coagulation
Correct Answer: D
Rationale: Severe postpartum hemorrhage increases the risk of disseminated intravascular coagulation (DIC), a life-threatening condition requiring urgent assessment.
What is the most important assessment for the nurse to conduct following the administration of epidural anesthesia to a client who is at 40-weeks gestation?
- A. Level of pain sensation.
- B. Variability of fetal heart rate
- C. Maternal blood pressure
- D. Station of presenting part
Correct Answer: C
Rationale: Epidural anesthesia can cause a sudden drop in maternal blood pressure, which may affect placental perfusion, making blood pressure monitoring the priority.
After breast-feeding 10 minutes at each breast, a new mother calls the nurse to the postpartum room to help change the newborn's diaper. As the mother begins the diaper change, the newborn spits up the breast milk. What action should the nurse implement first?
- A. Place the newborn in a position with the head lower than the feet.
- B. Turn the newborn to the side and bulb suction the mouth and nares.
- C. Wipe away the spit-up and assist the mother with the diaper change
- D. Sit the newborn upright and burp by rubbing or patting the upper back
Correct Answer: D
Rationale: Sitting the newborn upright and burping helps release trapped air, which is a common cause of spitting up after feeding.
A pregnant client receives Rho(D) immune globulin after an amniocentesis. The day following the procedure the client calls the nurse to report a temperature of 99.8° F (37.67°C). Which action should the nurse implement?
- A. Instruct the client to maintain bed rest for 24 hours.
- B. Encourage the client to increase her intake of oral fluids
- C. Schedule a visit with the healthcare provider today
- D. Verify the administered Rho(D) immune globulin's compatibility
Correct Answer: C
Rationale: A temperature elevation post-amniocentesis may indicate infection, requiring prompt evaluation by a healthcare provider.