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A nurse is admitting a client to the labor and delivery unit when the client states, 'My water just broke.' Which of the following interventions is the nurse's priority?
- A. Perform Nitrazine testing.
- B. Assess the fluid.
- C. Check cervical dilation.
- D. Begin FHR monitoring.
Correct Answer: D
Rationale: The correct answer is D: Begin FHR monitoring. This is the priority intervention because it assesses the well-being of the fetus immediately after the client's water breaking. Monitoring the fetal heart rate can provide crucial information on the baby's status and help identify any signs of distress. Performing Nitrazine testing (A) or checking cervical dilation (C) can be done after ensuring fetal well-being. Assessing the fluid (B) can confirm if the amniotic sac has indeed ruptured but does not provide immediate information on fetal status.
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A nurse is caring for a newborn who is 70 hr old. Which of the following findings should the nurse report to the provider? (Select all that apply.)
- A. Respiratory findings
- B. Temperature
- C. Oxygen Saturation
- D. Central nervous system findings
- E. Gastrointestinal findings
Correct Answer: A, D, E
Rationale: The correct answers are A (Respiratory findings), D (Central nervous system findings), and E (Gastrointestinal findings). These are crucial areas to monitor in a newborn to ensure their well-being. Respiratory findings are important as newborns are prone to respiratory distress. Central nervous system findings are vital for assessing neurological status. Gastrointestinal findings are necessary to monitor feeding tolerance and bowel movements. Temperature, oxygen saturation, and other choices are also important but may not be as critical in this case. It is essential to focus on the key areas that can indicate potential issues and require immediate attention.
A nurse is caring for a client who is in labor and reports increasing rectal pressure. They are experiencing contractions 2 to 3 min apart, each lasting 80 to 90 seconds, and a vaginal examination reveals that their cervix is dilated to 9 cm. The nurse should identify that the client is in which of the following phases of labor?
- A. Passive descent.
- B. Active.
- C. Early.
- D. Descent.
Correct Answer: D
Rationale: The correct answer is D: Descent. At 9 cm dilation, the client is in the second stage of labor, which consists of the descent and birth of the baby. Increasing rectal pressure indicates fetal descent and impending birth. Contractions 2-3 min apart lasting 80-90 seconds are characteristic of the active phase of the second stage of labor. The passive descent phase occurs earlier when the cervix is not fully dilated. The early phase is part of the first stage of labor. Active labor typically begins when the cervix is around 6 cm dilated. Therefore, D is the correct choice as it aligns with the client's symptoms and stage of labor progression.
A nurse is caring for a client who is at 22 weeks of gestation and is HIV positive. Which of the following actions should the nurse take?
- A. Administer penicillin G 2.4 million units IM to the client.
- B. Instruct the client to schedule annual pelvic examination.
- C. Tell the client they will start medication for HIV immediately after delivery.
- D. Report the client's condition to the local health Department.
Correct Answer: D
Rationale: The correct answer is D: Report the client's condition to the local health department. This is important to ensure proper monitoring, follow-up, and infection control measures. Reporting is necessary for contact tracing, prevention of transmission, and accessing appropriate support services. Administering penicillin G (A) is not indicated for HIV; the client needs antiretroviral therapy. Scheduling annual pelvic exams (B) is important for general health but not specific to HIV care. Waiting until after delivery to start HIV medication (C) is not recommended as timely treatment is crucial.
For each assessment finding, click to specify if the finding is consistent with hypoglycemia, hyperbilirubinemia, or sepsis.
- A. Ecchymotic caput Succedaneum.
- B. Decreased temperature.
- C. Lethargy.
- D. Poor feeding.
- E. Respiratory distress.
- F. Yellow sclera and oral mucosa.
Correct Answer: B, C, D, E, F
Rationale: The correct answer is because decreased temperature (B), lethargy (C), poor feeding (D), respiratory distress (E), and yellow sclera and oral mucosa (F) are consistent with hypoglycemia, hyperbilirubinemia, and sepsis. Decreased temperature can indicate hypoglycemia, lethargy and poor feeding can be seen in hypoglycemia and sepsis, respiratory distress can be a sign of sepsis, and yellow sclera and oral mucosa can be indicative of hyperbilirubinemia. Ecchymotic caput succedaneum is more related to birth trauma and is not specific to these conditions.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing. 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
- A. Place newborn skin to skin on birthing parents chest, Encourage birthing parents to breastfeed, Obtain prescription for arterial blood gases, Plan to initiate phototherapy, Perform neonatal abstinence system scoring
- B. Cold stress, Acute bilirubin encephalopathy, Respiratory distress syndrome, Neonatal abstinence syndrome (NAS)
- C. Stool output, Temperature, Lung sounds, Blood glucose level, Bilirubin level
Correct Answer:
Rationale: Action to Take: A, B; Potential Condition: B; Parameter to Monitor: C, E.
Rationale:
The correct answer is to place the newborn skin to skin on the birthing parent's chest and encourage breastfeeding to address Cold stress, a potential condition the client is most likely experiencing. These actions help regulate the newborn's temperature and provide essential warmth and nutrition. Parameters to monitor would include temperature (to assess for hypothermia) and bilirubin level (to monitor for jaundice, a common issue in newborns). Monitoring these parameters will help the nurse assess the client's progress and ensure appropriate interventions are implemented.