Nokea
A client in labor receiving an epidural reports feeling lightheaded and nauseous. What is the nurse's priority intervention?
- A. Administer antiemetics as prescribed.
- B. Check maternal blood pressure.
- C. Increase the oxytocin infusion rate.
- D. Encourage the client to lie on her back.
Correct Answer: B
Rationale: Lightheadedness and nausea can be signs of hypotension, a common side effect of epidural anesthesia.
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A client at 32 weeks' gestation reports regular uterine contractions every 10 minutes. What is the nurse's priority action?
- A. Administer tocolytic medication as prescribed.
- B. Perform a sterile vaginal examination.
- C. Assess for cervical changes and fetal heart rate.
- D. Encourage ambulation to relieve discomfort.
Correct Answer: C
Rationale: Assessing cervical changes and fetal heart rate is essential to determine whether the client is in preterm labor.
Pregnant Black people have more complications resulting from epigenetic changes caused by prolonged stress due to racism and discrimination. What complication could arise because of this history?
- A. postterm pregnancy
- B. preeclampsia
- C. liver disease
- D. cholestasis of pregnancy
Correct Answer: B
Rationale: Prolonged stress and systemic racism contribute to higher rates of preeclampsia in Black pregnant individuals.
The nurse is caring for a client at 38 weeks' gestation with suspected placental abruption. What is the priority nursing action?
- A. Assess maternal vital signs and fetal heart rate.
- B. Prepare the client for immediate cesarean delivery.
- C. Administer oxygen at 2 L/min via nasal cannula.
- D. Insert an indwelling urinary catheter.
Correct Answer: A
Rationale: Assessing maternal and fetal status is the first step to determine the urgency and appropriate intervention.
Which newborn is at highest risk of a skin infection? of the FHR?
- A. Infant born at 36 weeks who is being bottle fed
- B. Right lower abdomen
- C. Infant whose umbilical cord fell off on day 8 of life
- D. Near client umbilicus
Correct Answer: C
Rationale: The newborn infant whose umbilical cord fell off on day 8 of life is at highest risk of a skin infection. This is because the umbilical cord stump is an area prone to bacterial colonization and can lead to infection if proper care is not maintained during the cord care period. Once the umbilical cord falls off, the skin in that area is exposed and vulnerable to infection. It is important to educate parents on proper cord care techniques to prevent infection in this high-risk period.
The nurse is educating a client about exercises during pregnancy. What activity should be avoided?
- A. Swimming.
- B. Walking.
- C. Contact sports.
- D. Prenatal yoga.
Correct Answer: C
Rationale: Contact sports pose a risk of trauma to the mother and fetus and should be avoided during pregnancy.