Nokea
A nurse is caring for a client who becomes unresponsive upon delivery of the placenta. Which of the following actions should the nurse take first?
- A. Determine respiratory function.
- B. Increase the IV fluid rate.
- C. Access emergency medications from cart.
- D. Collect a maternal blood sample for coagulopathy studies.
Correct Answer: A
Rationale: The correct action for the nurse to take first is to determine respiratory function (Choice A). This is because an unresponsive client may be experiencing respiratory distress, which is a life-threatening situation requiring immediate intervention. Assessing respiratory function will help the nurse identify if the client is breathing adequately or if there is a need for immediate respiratory support such as airway management or assisted ventilation.
Increasing the IV fluid rate (Choice B), accessing emergency medications (Choice C), and collecting a blood sample for coagulopathy studies (Choice D) are important interventions but are not the priority in this scenario. Respiratory function takes precedence as airway and breathing are essential for life and must be addressed first to ensure the client's safety and well-being.
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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: The correct answer is C: Assist the client to empty their bladder. Palpating the uterus above the umbilicus 12 hours postpartum indicates uterine displacement due to a full bladder. A distended bladder can displace the uterus, leading to uterine atony and increased risk of postpartum hemorrhage. By assisting the client to empty their bladder, the nurse can help the uterus return to its proper position, reducing the risk of complications. Reassessing the client in 2 hours (A) does not address the immediate issue of bladder distention. Administering simethicone (B) is indicated for gas relief and not related to the palpated uterus. Instructing the client to lie on their right side (D) may be uncomfortable and does not address the underlying bladder distention.
A nurse is caring for a client who is at 38 weeks of gestation. Which of the following actions should the nurse take prior to applying an external transducer for fetal monitoring?
- A. Determine progression of dilatation and effacement.
- B. Perform Leopold maneuvers.
- C. Complete a sterile speculum exam.
- D. Prepare a Nitrazine paper test.
Correct Answer: B
Rationale: The correct answer is B: Perform Leopold maneuvers. Prior to applying an external transducer for fetal monitoring at 38 weeks of gestation, the nurse should perform Leopold maneuvers to determine the position of the fetus, fetal lie, presentation, and engagement. This helps in locating the fetal back and identifying the optimal placement for the transducer. Progression of dilatation and effacement (choice A) is more relevant for labor assessment. Completing a sterile speculum exam (choice C) is not necessary for fetal monitoring. Preparing a Nitrazine paper test (choice D) is used to assess for rupture of membranes, not for applying an external transducer.
A nurse is caring for a client who is at 37 weeks of gestation and is being tested for group B streptococcus ß-hemolytic (GBS). The client is multigravida and multipara with no history of GBS. She asks the nurse why the test was not conducted earlier in her pregnancy. Which of the following is an appropriate response by the nurse?
- A. You didn't report any symptoms of GBS during your pregnancy.'
- B. Your previous deliveries were all negative for GBS.'
- C. There was no indication of GBS in your earlier prenatal testing.'
- D. We need to know if you are positive for GBS at the time of delivery.'
Correct Answer: D
Rationale: The correct answer is D: "We need to know if you are positive for GBS at the time of delivery." This response is appropriate because GBS status can change during pregnancy, and testing closer to the delivery date provides the most up-to-date information. Testing earlier in pregnancy may not accurately reflect the GBS status at the time of delivery.
Choice A is incorrect because the presence of symptoms is not a reliable indicator of GBS status. Choice B is incorrect as past negative GBS results do not guarantee the current status. Choice C is incorrect because GBS screening is typically done later in pregnancy regardless of earlier test results.
A nurse is caring for a client who is in active labor with a fetus in the occipitoposterior position. The nurse assists the client into a hands-and-knees position. Which of the following questions should the nurse ask to evaluate the effectiveness of this intervention?
- A. Does that lessen your suprapubic pain?
- B. Are you feeling relief from your pelvic pressure?
- C. Do your contractions feel further apart?
- D. Has your back labor improved?
Correct Answer: D
Rationale: The correct answer is D: "Has your back labor improved?" This question is crucial because the occipitoposterior position can cause intense back pain during labor. By asking if the back labor has improved, the nurse can assess the effectiveness of the hands-and-knees position in helping relieve the client's discomfort. A: "Does that lessen your suprapubic pain?" is incorrect because suprapubic pain is not specifically associated with occipitoposterior positioning. B: "Are you feeling relief from your pelvic pressure?" is incorrect as it does not directly address the back pain associated with occipitoposterior positioning. C: "Do your contractions feel further apart?" is incorrect as it does not focus on the back pain issue. The key is to address the specific discomfort caused by the occipitoposterior position.
A nurse is assessing a late preterm newborn. Which of the following manifestations is an indication of hypoglycemia?
- A. Hypertonia
- B. Increased feeding
- C. Hyperthermia
- D. Respiratory distress
Correct Answer: D
Rationale: Correct Answer: D - Respiratory distress
Rationale: Hypoglycemia in a late preterm newborn can lead to respiratory distress due to inadequate glucose supply to the brain, causing dysfunction in respiratory centers. This can manifest as tachypnea, grunting, nasal flaring, and retractions. Hypertonia, increased feeding, and hyperthermia are not specific signs of hypoglycemia in newborns.
Summary:
A: Hypertonia is not a typical manifestation of hypoglycemia in newborns.
B: Increased feeding is more likely to be seen in newborns with hunger cues, not necessarily indicative of hypoglycemia.
C: Hyperthermia is not a common sign of hypoglycemia in newborns.