Nokea
A client in labor is receiving an epidural for pain relief. What is the nurse's priority assessment immediately after the procedure?
- A. Monitor maternal blood pressure.
- B. Assess fetal heart rate.
- C. Check for bladder distention.
- D. Evaluate the client's pain level.
Correct Answer: A
Rationale: Monitoring maternal blood pressure is essential to detect and manage hypotension, a common side effect of epidurals.
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A nurse is caring for a client who is 14 weeks of gestation. At which the following locations should the nurse place the Doppler device when assessing the fetal heart rate?
- A. Midline 2 to 3 cm (0.8 to 1.2 in) above the symphysis pubis
- B. Left Upper Abdomen
- C. Two fingerbreadths above the umbilicus
- D. Lateral at the Xiphoid Process
Correct Answer: A
Rationale: When assessing the fetal heart rate in a client who is 14 weeks of gestation, the nurse should place the Doppler device at the midline 2 to 3 cm above the symphysis pubis. This is the appropriate location for detecting the fetal heartbeat at this gestational age. Placing the Doppler device too high on the abdomen may result in difficulty in detecting the fetal heart rate due to the position of the uterus and fetal size. Placing it too low may not capture the fetal heartbeat accurately. Therefore, the midline location above the symphysis pubis provides the best chance for accurate assessment of the fetal heart rate at 14 weeks of gestation.
A nurse is caring for a client who is at 39 weeks of gestation and is in active labor. The nurse locates the fetal heart tones above the client's umbilicus at midline. The nurse should suspect that the fetus is in which of the following positions?
- A. Cephalic
- B. Transverse
- C. Posterior
- D. Frank breech
Correct Answer: A
Rationale: When the nurse locates the fetal heart tones above the client's umbilicus at midline, it indicates that the fetus is in a cephalic position. In this position, the baby's head is facing downward towards the birth canal, which is the optimal position for a vaginal delivery. This positioning is considered normal and favorable for childbirth.
The nurse is caring for a client in active labor with late decelerations on the monitor. What is the priority nursing intervention?
- A. Reposition the client to her side.
- B. Administer IV fluids.
- C. Apply oxygen via face mask.
- D. Notify the healthcare provider.
Correct Answer: A
Rationale: Repositioning improves blood flow and oxygen delivery to the fetus during late decelerations.
After her baby's birth a patient wishes to begin breastfeeding. The nurse assists the client by:
- A. Positioning the infant to grasp the nipple to express milk.
- B. Giving the infant a bottle first to evaluate the baby's ability to suck
- C. Leaving them alone and allowing the infant to nurse as long as desired
- D. Touching the infant's cheek adjacent to the nipple to elicit the rooting reflex
Correct Answer: A
Rationale: Positioning the infant to grasp the nipple to express milk is an essential step in helping the patient begin breastfeeding successfully. As a nurse, it is crucial to ensure that the infant is properly latched onto the breast to facilitate effective feeding and milk transfer. This involves positioning the infant in a way that allows them to effectively grasp the nipple, promoting proper suckling and milk production. By assisting the patient in positioning the infant correctly, the nurse is supporting the establishment of successful breastfeeding and ensuring optimal nutrition for the baby.
When evaluating cervical mucus, what is the quality of spinnbarkeit?
- A. elasticity
- B. amount
- C. clarity
- D. color
Correct Answer: A
Rationale: The quality of spinnbarkeit refers to the elasticity of cervical mucus. Spinnbarkeit is a term used to describe the stretchability or stretchy quality of cervical mucus during ovulation. This elasticity is an important characteristic as it indicates the fertile window for a woman trying to conceive. High levels of spinnbarkeit allow for easier passage and survival of sperm, increasing the chances of conception. The other choices (B. amount, C. clarity, D. color) do not specifically refer to the stretchability or elasticity of cervical mucus, which is what is assessed when evaluating spinnbarkeit.