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 30-year-old woman is considering the use of emergency contraception. Which of the following is true about its use?
- A. It is most effective when used within 72 hours after unprotected sex.
- B. It should be used at least 5 days after unprotected sex to be effective.
- C. It prevents implantation of a fertilized egg into the uterine wall.
- D. It requires a prescription from a healthcare provider.
Correct Answer: A
Rationale: Emergency contraception is most effective when taken within 72 hours of unprotected sex. Choice B is incorrect as it is not as effective after 5 days. Choice C is incorrect because emergency contraception works primarily by preventing ovulation, not by preventing implantation. Choice D is incorrect because most emergency contraception methods are available over the counter.
The nurse is caring for a client with severe preeclampsia. What finding would indicate magnesium sulfate toxicity?
- A. Increased deep tendon reflexes.
- B. Respiratory rate of 10 breaths per minute.
- C. Urine output of 50 mL/hour.
- D. Blood pressure of 160/110 mmHg.
Correct Answer: B
Rationale: Respiratory depression is a key sign of magnesium sulfate toxicity, requiring immediate action.
Which newborn is at higher risk for developing hypoglycemia? SATA
- A. SGA
- B. Post term newborn
- C. LGA
- D. 38 week gestation (term newborn)
Correct Answer: A
Rationale: - Small for gestational age (SGA) newborns are at higher risk for developing hypoglycemia due to limited glycogen stores and decreased adipose tissue for energy reserve.
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.
A client at 16 weeks' gestation asks about the purpose of a maternal serum alpha-fetoprotein (MSAFP) test. What is the nurse's best response?
- A. It screens for chromosomal abnormalities.
- B. It detects neural tube defects.
- C. It confirms the gestational age of the baby.
- D. It identifies the baby's sex.
Correct Answer: B
Rationale: The MSAFP test is used to screen for neural tube defects such as spina bifida.