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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: The first action is to massage the client's fundus, as uterine atony is a common cause of postpartum hemorrhage, and this intervention can help stimulate uterine contraction and reduce bleeding.
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A nurse is caring for a client who is in the third trimester of pregnancy and has gestational diabetes. Which of the following complications is the fetus at risk for?
- A. Macrosomia
- B. Hydrocephalus
- C. Cleft palate
- D. Spina bifida
Correct Answer: A
Rationale: Gestational diabetes can result in fetal macrosomia, a condition where the baby grows larger than normal due to excess glucose in the mother's blood. This increases the risk of complications during delivery.
A nurse is caring for a laboring client and notes that the fetal heart rate begins to decelerate after the contraction has started. The lowest point of deceleration occurs after the peak of the contraction. What is the priority nursing action?
- A. Administer oxygen
- B. Change the client's position
- C. Increase IV fluids
- D. Call the healthcare provider
Correct Answer: B
Rationale: Late decelerations are caused by uteroplacental insufficiency, indicating that the fetus is not receiving adequate oxygen during contractions. This is an emergency that requires prompt intervention. Changing the client's position helps to improve placental blood flow, which can reduce the stress on the fetus. If the decelerations continue, further interventions, including oxygen administration and notifying the provider, may be necessary.
A client is being treated with eclampsia. What is a priority nursing intervention?
- A. Assess for hyperreflexia
- B. Administer oxygen
- C. Monitor blood pressure every 15 minutes
- D. Prepare for delivery
Correct Answer: A
Rationale: Eclampsia is a serious complication of pregnancy characterized by seizures. Hyperreflexia is often a precursor to eclampsia, and assessing for it can help predict and manage the condition before seizures occur.
A nurse is providing education to a client in the first trimester of pregnancy. What information should the nurse include regarding the cause of indigestion and heartburn?
- A. Estrogen causes increased appetite
- B. Progesterone causes relaxation of the cardiac sphincter allowing acid to reflux
- C. HCG hormone leads to increased gastric acidity
- D. The uterus compresses the stomach early in pregnancy
Correct Answer: B
Rationale: Progesterone causes relaxation of the smooth muscles in the body, including the cardiac sphincter. This allows stomach acid to reflux into the esophagus, causing heartburn, especially during pregnancy.
To decrease the incidence of sudden infant death syndrome (SIDS), the parents will position the newborn in a:
- A. Prone position
- B. Supine position
- C. Side-lying position
- D. Semi-fowler's position
Correct Answer: B
Rationale: The safest sleeping position for infants is on their back (supine position). This reduces the risk of sudden infant death syndrome (SIDS), as sleeping in other positions can increase the risk of airway obstruction.