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Client at 35 weeks of gestation experiencing mild vaginal bleeding due to placenta previa.
A nurse is admitting a client who is at 35 weeks of gestation and is experiencing mild vaginal bleeding due to placenta previa. Which of the following actions should the nurse plan to take?
- A. Initiate continuous monitoring of the FHR.
- B. Administer a dose of betamethasone.
- C. Check the cervix for dilation every 8 hr.
- D. Request that the provider prescribe misoprostol PRN.
Correct Answer: A,B
Rationale: Continuous monitoring of fetal heart rate (A) provides early detection of distress in placenta previa cases. Betamethasone (B) accelerates fetal lung maturity, reducing the risk of respiratory distress syndrome if preterm delivery occurs.
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Newborn whose mother had gestational diabetes mellitus.
A nurse is assessing a newborn whose mother had gestational diabetes mellitus. Which of the following findings should the nurse identify as a manifestation of hypoglycemia?
- A. Jitteriness.
- B. Hypertonia.
- C. Acrocyanosis of the hands.
- D. Generalized petechiae.
Correct Answer: A
Rationale: Jitteriness indicates hypoglycemia in newborns as glucose is critical for neonatal brain function. Blood glucose less than 45 mg/dL supports this diagnosis, requiring prompt intervention to avoid neurological harm.
Client has been pushing for 2.5 hours with minimal progress, fetal head remains at +2 station.
A nurse in the labor and delivery triage unit assesses a client who has been pushing for 2.5 hours with minimal progress. The fetal head remains at +2 station. Which of the following is the most appropriate next action?
- A. Perform a vaginal exam to reassess effacement and dilation.
- B. Notify the primary health care provider about minimal progress.
- C. Prepare the client for vacuum-assisted delivery.
- D. Administer intravenous oxytocin.
Correct Answer: B
Rationale: Notifying the primary health care provider about minimal progress is the most appropriate next action. The client has been pushing for 2.5 hours with minimal progress, which raises concern for potential complications such as cephalopelvic disproportion or maternal exhaustion.
Client who is breastfeeding and has mastitis.
A nurse is planning care for a client who is breastfeeding and has mastitis. Which of the following interventions should the nurse include?
- A. Instruct the client to wash their hands prior to breastfeeding.
- B. Teach the client about proper latching-on techniques.
- C. Encourage the client to alternate breastfeeding with formula feeding.
- D. Encourage the client to allow their nipples to air dry after feedings.
Correct Answer: A,B,D
Rationale: Handwashing (A) minimizes pathogen transmission. Proper latching techniques (B) reduce nipple trauma and facilitate milk drainage. Allowing nipples to air dry (D) promotes healing and reduces infection risk.
Client gave birth 4 hr ago and is experiencing excessive vaginal bleeding.
A nurse is caring for a client who gave birth 4 hr ago and is experiencing excessive vaginal bleeding. Which of the following actions should the nurse plan to take first?
- A. Elevate the client's legs to a 30° angle.
- B. Insert an indwelling urinary catheter.
- C. Massage the client's fundus.
- D. Initiate an infusion of oxytocin.
Correct Answer: C
Rationale: Massaging the fundus promotes uterine contraction, which is the first-line intervention to control postpartum hemorrhage caused by uterine atony.
Client reports feeling well, findings include: General: No acute distress. Cardiovascular: No murmur or rub. Respiratory: Bilateral breath sounds clear. Abdomen: Fundal height 38 cm. Genitourinary: Purulent cervical discharge.
A nurse conducts a physical exam of a client who reports feeling well. Which finding requires clinical intervention?
- A. No acute distress.
- B. No murmur or rub.
- C. Bilateral breath sounds clear.
- D. Fundal height 38 cm.
- E. Purulent cervical discharge.
Correct Answer: E
Rationale: Purulent cervical discharge suggests an ongoing infection, likely bacterial cervicitis. It reflects leukocyte accumulation due to pathogenic invasion, requiring clinical intervention to prevent complications.