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A client who had a vaginal delivery 2 hours earlier has just been transferred to the postpartum unit from labor and delivery. Which of the following nursing care goals is of highest priority?
- A. The client will breastfeed her baby every 2 hours.
- B. The client will consume a nutritious diet.
- C. The client will have a moderate lochial flow.
- D. The client will ambulate in the hallways every shift.
Correct Answer: C
Rationale: Ensuring the client has a moderate lochial flow is a priority to monitor for postpartum hemorrhage.
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Which finding indicates the best quality improvement process?
- A. Staff identifies the wait time in the emergency department is too long.
- B. Administration identifies the design of the facility’s lobby increases patient stress.
- C. Director of the hospital identifies the payment schedule does not pay enough for overtime.
- D. Health care providers identify the inconsistencies of some of the facility’s policy and procedures.
Correct Answer: A
Rationale: The quality improvement process begins at the staff level, where problems are defined by the staff. It is not identified by administration, the hospital director, or health care providers.
A fetus, descending through the birth canal, is going through the cardinal moves of labor. Please place the following moves in chronological order.
- A. External rotation.
- B. Flexion.
- C. Extension.
- D. Internal rotation.
Correct Answer: D
Rationale: The cardinal movements of labor occur in the following order: flexion, internal rotation, extension, external rotation, and expulsion.
Use Naegele's rule to determine the EDD (estimated day of birth) for a patient whose last menstrual period started on April 12.
- A. 19-Feb
- B. 19-Jan
- C. 21-Jan
- D. 7-Feb
Correct Answer: B
Rationale: To calculate EDD using Naegele's rule, add 7 days to the first day of the last menstrual period, then count back 3 months and add 1 year. For this question, starting with April 12, adding 7 days gives April 19. Counting back 3 months gives January 19 of the following year. Therefore, the estimated day of birth (EDD) is January 19. Choice B (19-Jan) is correct.
Choice A (19-Feb): Incorrect as it does not follow the correct calculation method for Naegele's rule.
Choice C (21-Jan): Incorrect as the calculation does not match the steps of Naegele's rule.
Choice D (7-Feb): Incorrect as it does not align with the correct application of Naegele's rule.
A newly pregnant patient tells the nurse that she has irregular periods and is unsure of when she got pregnant. Scheduling an ultrasound is a standing prescription for the patient's health care provider. When is the best time for the nurse to schedule the patient's ultrasound?
- A. Immediately
- B. In 2 weeks
- C. In 4 weeks
- D. In 6 weeks
Correct Answer: A
Rationale: The best time to schedule the ultrasound immediately is because in early pregnancy, it is crucial to confirm the gestational age, rule out ectopic pregnancy, and assess fetal viability. This allows for accurate dating, identification of potential complications, and timely interventions if needed. Waiting for 2, 4, or 6 weeks could delay necessary care and potentially compromise the well-being of the patient and the fetus. Early detection and management of any issues are essential in ensuring a healthy pregnancy outcome.
A woman who states that she smokes 2 packs of cigarettes each day is admitted to the labor and delivery suite in labor. The nurse should monitor this labor for which of the following?
- A. Delayed placental separation.
- B. Late decelerations.
- C. Shoulder dystocia.
- D. Precipitous fetal descent.
Correct Answer: B
Rationale: Smoking during pregnancy is associated with placental insufficiency, which can lead to late decelerations in the fetal heart rate.