Nokea
A client is in active labor and is receiving an epidural for pain relief. Which of the following should the nurse monitor as the priority?
- A. Fetal heart rate
- B. Client's blood pressure
- C. Client's respiratory rate
- D. Client's pain level
Correct Answer: B
Rationale: The most common side effect of an epidural is hypotension, which can compromise placental perfusion. Monitoring the client's blood pressure is the priority to ensure maternal and fetal well-being.
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A nurse is caring for a client who is 28 weeks pregnant and has preeclampsia. Which of the following is the priority assessment?
- A. Level of consciousness
- B. Deep tendon reflexes
- C. Blood pressure
- D. Urinary output
Correct Answer: C
Rationale: Blood pressure is the priority assessment in clients with preeclampsia because hypertension is the primary symptom of the condition. Elevated blood pressure increases the risk of complications such as eclampsia and placental abruption.
During a breast examination on a 24-year-old client the nurse notes the following findings. Which finding is of most concern and should be reported to the provider?
- A. An irregularly shaped, nontender lump is palpable in the right breast
- B. Tenderness is present during menstruation
- C. Bilateral, symmetrical lumps that move with palpation
- D. The client reports breast tenderness before menstruation
Correct Answer: A
Rationale: An irregularly shaped, nontender lump is a concerning finding because it may indicate breast cancer. The nurse should report this finding to the provider for further investigation.
A nurse is teaching a client who is Rh-negative about Rh (D) immune globulin. Which of the following statements by the client indicates an understanding of the teaching?
- A. If my partner is Rh-negative, I will not receive the shot.
- B. I will receive the shot after delivery if my baby is Rh-negative.
- C. I should not receive any immunizations for 3 months after the shot.
- D. This shot may be given after birth to protect future pregnancies.
Correct Answer: D
Rationale: The client's statement correctly reflects that Rh immune globulin is administered after delivery to prevent sensitization in future pregnancies, especially if the baby is Rh-positive.
A nurse is assessing a client 2 hours after a vaginal delivery and notes that the client's uterus is boggy and displaced to the right. Which of the following interventions should the nurse perform first?
- A. Assist the client to void
- B. Massage the uterus
- C. Administer oxytocin
- D. Encourage breastfeeding
Correct Answer: A
Rationale: A boggy and displaced uterus is often a sign of bladder distention, which can prevent the uterus from contracting effectively. The priority intervention is to assist the client to void, which will allow the uterus to return to midline and become firm.
A client tells the nurse that she suspects she is pregnant because she is able to feel the baby move. The nurse knows that this is a:
- A. Presumptive sign of pregnancy
- B. Probable sign of pregnancy
- C. Positive sign of pregnancy
- D. Possible sign of pregnancy
Correct Answer: A
Rationale: Quickening, or the sensation of fetal movement, is considered a presumptive sign of pregnancy. It is not definitive because other conditions, such as gas or intestinal movement, can mimic the feeling of fetal movement.