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A nurse is assessing a client who gave birth vaginally 12 hr ago and palpates their uterus to the right above the umbilicus. Which of the following interventions should the nurse perform?
- A. Reassess the client in 2 hr.
- B. Administer simethicone.
- C. Assist the client to empty their bladder.
- D. Instruct the client to lie on their right side.
Correct Answer: C
Rationale: A displaced uterus to the right above the umbilicus may indicate a full bladder. Assisting the client to empty their bladder helps the uterus return to its proper position and prevents complications like postpartum hemorrhage.
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A nurse is developing a plan of care for a newborn whose mother tested positive for heroin during pregnancy. The newborn is experiencing neonatal abstinence syndrome. Which of the following actions should the nurse include in the plan?
- A. Administer naloxone to the newborn.
- B. Swaddle the newborn with his legs extended.
- C. Maintain eye contact with the newborn during feedings
- D. Minimize noise in the newborn's environment.
Correct Answer: D
Rationale: Minimizing noise in the newborn's environment helps reduce overstimulation, which can exacerbate symptoms of neonatal abstinence syndrome. Naloxone is not used for this condition, and swaddling with legs extended is incorrect as it should be snug to provide comfort.
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 priority intervention is to begin FHR (fetal heart rate) monitoring to ensure the fetus is not in distress after the rupture of membranes. This is critical for fetal well-being.
Which of the following hormones stimulates uterine contractions during labor?
- A. Progesterone
- B. Estrogen
- C. Prolactin
- D. Oxytocin
Correct Answer: D
Rationale: Oxytocin is the hormone responsible for stimulating uterine contractions during labor.
Which of the following is a professional standard for nursing practice in maternal and newborn healthcare?
- A. Collaboration with interdisciplinary team members
- B. Advocacy for patients and families
- C. Incorporation of evidence-based practice
- D. All of the above
Correct Answer: D
Rationale: The correct answer is D, all of the above. Collaboration with interdisciplinary team members is crucial in providing holistic care in maternal and newborn healthcare. Advocacy for patients and families ensures their rights and preferences are respected. Incorporation of evidence-based practice ensures that nursing care is based on the best available research and clinical expertise. Therefore, selecting all of the above options is essential to uphold professional standards in nursing practice in maternal and newborn healthcare.
A nurse is caring for a client who is receiving oxytocin via continuous IV infusion and is experiencing persistent late decelerations in the FHR. After discontinuing the infusion, which of the following actions should the nurse take?
- A. Instruct the client to bear down and push with contractions.
- B. Administer oxygen at 10 L/min via nonrebreather facemask.
- C. Place the client in a supine position.
- D. Initiate an amnioinfusion.
Correct Answer: B
Rationale: The correct answer is B: Administer oxygen at 10 L/min via nonrebreather facemask. Late decelerations in FHR during oxytocin infusion indicate uteroplacental insufficiency. Administering oxygen helps improve oxygenation to the fetus, potentially alleviating the late decelerations. This action addresses the underlying cause and supports fetal oxygenation. In contrast, option A may increase intrauterine pressure, worsening fetal distress. Option C (supine position) can further compromise placental perfusion. Option D (amnioinfusion) is used for variable decelerations, not late decelerations.