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A nurse is assessing a client following an amniocentesis. Which of the following findings should the nurse recognize as complications? (SATA).
- A. Amnionitis,Leakage of amniotic fluidPreterm labor
- B. Hypertension
- C. Hyperglycemia
- D. Maternal hypotension
Correct Answer: A
Rationale: The correct answer is A because amnionitis, leakage of amniotic fluid, and preterm labor are potential complications following amniocentesis. Amnionitis is an infection of the amniotic fluid, leakage of amniotic fluid can lead to preterm labor, and preterm labor poses risks to both the mother and the baby. Hypertension (B), hyperglycemia (C), and maternal hypotension (D) are not commonly associated with amniocentesis and are not typical complications of the procedure.
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A nurse is caring for four antepartum clients. Which of the following clients should the nurse assess first?
- A. A client who is at 7 weeks of gestation and reports urinary frequency
- B. A client who is at 32 weeks of gestation and reports seeing floating spots
- C. A client who is 38 weeks of gestation and reports leg cramps
- D. A client who is at 20 weeks of gestation and reports periodic numbness in her fingers
Correct Answer: B
Rationale: The correct answer is B. The nurse should assess the client who is at 32 weeks of gestation and reports seeing floating spots first. Seeing floating spots could be a sign of preeclampsia, a serious pregnancy complication characterized by high blood pressure and organ damage. Preeclampsia can lead to severe complications for both the mother and the baby if not managed promptly. Therefore, this client needs immediate assessment to rule out preeclampsia and ensure appropriate interventions are initiated. Choices A, C, and D do not present with urgent signs or symptoms that require immediate attention compared to the potential severity of preeclampsia in choice B.
A nurse is preparing to perform a fundal massage for a postpartum client with hearing seeing uterine atony. In which order should the nurse plan to perform the following actions? (molded steps into the box on the right. Placing them in order of performance use all steps)
- A. Ask the client to lie on her back with her knees flexed
- B. Position one hand around the top of the client's fundus and one hand just above the client's symphysis pubis
- C. Rotate the upper hand to massage the client's uterus while using slight downward pressure to compress the fundus
- D. Observe the client's perineum for the passage of clots and the amount of bleeding
Correct Answer: A,B,C.D
Rationale: The correct order for performing fundal massage is A, B, C, and D. First, asking the client to lie on her back with knees flexed (A) allows for proper positioning. Then, positioning one hand around the top of the fundus and one hand above the symphysis pubis (B) ensures correct placement for the massage. Next, rotating the upper hand to massage the uterus while applying slight downward pressure (C) facilitates uterine contractions. Finally, observing the perineum for clots and bleeding (D) helps monitor postpartum hemorrhage. Choices E, F, and G are not applicable to the process of performing a fundal massage and are therefore incorrect.
A nurse is planning care immediately following birth for a newborn who has myelomeningocele that is leaking cerebrospinal fluid.
- A. Administer broad-spectrum antibiotics
- B. Cleans the site with povidone-iodine
- C. Monitor the rectal temperature every 4 hours
- D. Prepare for surgical closure after 72 hours
Correct Answer: A
Rationale: The correct answer is A. Administering broad-spectrum antibiotics is crucial to prevent infection since the exposed spinal cord increases the risk. Antibiotics help reduce the risk of meningitis and sepsis. Choice B is incorrect as povidone-iodine can be irritating to the sensitive skin around the defect. Choice C is incorrect as monitoring rectal temperature is not directly related to the immediate care needed for a myelomeningocele. Choice D is incorrect because surgical closure should be done as soon as possible to prevent further complications.
A nurse on the labor and delivery unit is assessing four clients. Which of the following clients is a candidate for an induction of labor with misoprostol?
- A. A client who has active genital herpes
- B. A client who has gestational diabetes mellitus
- C. A client who has a previous uterine incision
- D. A client who has placenta previa
Correct Answer: B
Rationale: The correct answer is B: A client who has gestational diabetes mellitus. Induction of labor with misoprostol is safe for clients with gestational diabetes mellitus as it does not affect blood glucose levels. Misoprostol is contraindicated in clients with active genital herpes (Choice A) due to risk of viral transmission. It is also contraindicated in clients with a previous uterine incision (Choice C) as it may increase the risk of uterine rupture. Clients with placenta previa (Choice D) should not undergo induction with misoprostol due to the risk of increasing bleeding.
A nurse is observing an adolescent client who is offering her newborn a bottle while he is laying in the bassinet. When the nurse offers to pick the newborn up and place them in the client's arms, the mother states 'No, the baby is too tired to be held.' Which of the following actions should the nurse take?
- A. Insist that the mother pick up the newborn to feed him
- B. Demonstrate how to hold a newborn and allow the client to practice
- C. Persuade the client to breastfeed the newborn to promote bonding
- D. Offer to take the newborn to the nursery to finish his feeding
Correct Answer: B
Rationale: The correct answer is B: Demonstrate how to hold a newborn and allow the client to practice. This option respects the mother's decision while also providing education and support. By demonstrating proper newborn holding techniques and allowing the client to practice, the nurse can ensure the baby's safety and promote bonding between the mother and newborn. Insisting on the mother picking up the newborn (choice A) goes against her wishes and may create tension. Persuading the client to breastfeed (choice C) may not be feasible or appropriate at that moment. Taking the newborn to the nursery (choice D) may not align with the mother's preferences.