Nokea
A nurse has just inserted an orogastric gavage tube into a preterm baby. When would the nurse determine that the tube is in the proper location?
- A. When gastric aspirate is removed from the tube.
- B. When the baby suckles on the tubing.
- C. When respirations are unlabored during tube insertion.
- D. When the tubing can be inserted no farther.
Correct Answer: A
Rationale: The presence of gastric aspirate confirms that the tube is in the stomach, which is the proper location for feeding.
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A client’s vital signs during labor and delivery were: BP 100/58–110/66, T 98.6ºF–98.8ºF, P 72–80 bpm, R 20–24 rpm. The client’s vitals 2 hours postpartum are BP 100/56, TPR 99.4ºF, P 70 bpm, R 20 rpm. Which of the following actions should the nurse perform at this time?
- A. Check the client’s lochia flow.
- B. Ask the client if she is having chills.
- C. Encourage the client to drink fluids.
- D. Assess the client’s lung fields.
Correct Answer: A
Rationale: Checking the client’s lochia flow is important to ensure there is no excessive bleeding, which could indicate postpartum hemorrhage.
A nurse is following the PDSA cycle for quality improvement. Which action will the nurse take for the letter “A”?
- A. Act
- B. Alter
- C. Assess
- D. Approach
Correct Answer: A
Rationale: There are many models for quality improvement and performance improvement. One model is the PDSA cycle: plan, do, study, and act.
Which of the following complications of labor and delivery may develop when a baby enters the pelvis in the LMP position?
- A. Cephalopelvic disproportion.
- B. Placental abruption.
- C. Breech presentation.
- D. Acute fetal distress.
Correct Answer: A
Rationale: LMP (left mentum posterior) position can lead to cephalopelvic disproportion, making delivery difficult.
The nurse is teaching her client about the methods of electronic fetal monitoring during labor. Her client asks which method has the fewest risks to her baby and allows her the most freedom. What is the most appropriate response by the nurse?
- A. Internal and external monitoring have equal risks. You will have to remain in the bed with both of these methods.'
- B. Internal monitoring is a more invasive method, but we only use internal monitoring if we have difficulty obtaining accurate information with external monitoring.'
- C. External monitoring will allow you the most freedom of movement and does not require any invasive procedures for you or your baby.'
- D. External monitoring is not invasive but you have to remain in the bed.'
Correct Answer: C
Rationale: The correct answer is C because external monitoring allows the client the most freedom of movement and does not require any invasive procedures for her or the baby. External monitoring involves placing sensors on the abdomen to monitor the baby's heart rate and the mother's contractions. This method is non-invasive and allows the mother to move around during labor, promoting comfort and mobility.
Choice A is incorrect because internal monitoring is more invasive than external monitoring. Choice B is incorrect because internal monitoring is not used solely based on difficulty obtaining accurate information with external monitoring. Choice D is incorrect because external monitoring does not require the mother to remain in bed; she can move around freely.
During a vaginal delivery of a macrosomic baby, the nurse midwife requests nursing assistance. Which of the following actions by the nurse would be appropriate?
- A. Estimate fetal length and weight.
- B. Assess intensity of contractions.
- C. Provide suprapubic pressure.
- D. Assist woman with breathing.
Correct Answer: C
Rationale: Suprapubic pressure helps guide the baby’s shoulders during delivery, reducing the risk of shoulder dystocia.