Nokea
A nurse is caring for a client who is in labor and notes that the umbilical cord is prolapsed. Which of the following actions should the nurse take?
- A. Evaluate uterine tone.
- B. Loosely wrap the cord with petroleum gauze.
- C. Apply fundal pressure.
- D. Place the client in Trendelenburg position
Correct Answer: D
Rationale: Placing the client in the Trendelenburg position helps reduce pressure on the prolapsed cord, preventing fetal distress. Other actions like applying fundal pressure or wrapping the cord are not appropriate.
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A nurse is caring for a client who reports spontaneous rupture of membranes. The nurse observes fetal bradycardia on the FHR tracing and notices that the umbilical cord is protruding. After calling for assistance and notifying the provider, which of the following actions should the nurse take next?
- A. Perform a vaginal examination by applying upward pressure on the presenting part.
- B. Cover the umbilical cord with a sterile saline-saturated towel.
- C. Administer oxygen via nonrebreather mask at 8 L/min.
- D. Initiate an infusion of IV fluids for the client.
Correct Answer: B
Rationale: The correct answer is B: Cover the umbilical cord with a sterile saline-saturated towel. This action is crucial in preventing compression and desiccation of the umbilical cord, which could lead to decreased blood flow and oxygen delivery to the fetus. By covering the cord, the nurse can protect it from further damage while waiting for emergency intervention. Performing a vaginal examination (choice A) could worsen the situation by causing more pressure on the cord. Administering oxygen (choice C) may be important later but is not the immediate priority. Initiating IV fluids (choice D) is not the most urgent action in this scenario.
What is the recommended method of pain relief for a woman who has a cesarean delivery?
- A. Epidural anesthesia
- B. Intravenous opioids
- C. Patient-controlled analgesia
- D. All of the above
Correct Answer: D
Rationale: The correct answer is D: All of the above. After a cesarean delivery, a combination of pain relief methods is often recommended to manage postoperative pain effectively. Epidural anesthesia provides continuous pain relief, intravenous opioids offer immediate relief, and patient-controlled analgesia allows the woman to self-administer pain medication as needed. This multimodal approach ensures adequate pain control while minimizing side effects. Choosing only one method may not address all aspects of pain management. Therefore, utilizing all three options in combination is the most comprehensive and effective approach in managing pain after a cesarean delivery.
Which of the following nursing actions should the nurse plan to take? For each potential nursing action, click to specify it the intervention is indicated or contraindicated for the client.
- A. Insert a large bore intravenous catheter.
- B. Assess cervical dilation.
- C. Weigh perineal pads.
- D. Administer methotrexate.
Correct Answer: A, C
Rationale: Inserting a large bore IV catheter is indicated to manage potential hemorrhage. Weighing perineal pads helps quantify blood loss. Assessing cervical dilation is contraindicated as it may exacerbate bleeding. Administering methotrexate is not relevant in this context.
Which of the following is a potential legal issue related to maternal and newborn healthcare?
- A. Informed consent
- B. Medical malpractice
- C. Abandonment
- D. All of the above
Correct Answer: D
Rationale: The correct answer is D: All of the above. In maternal and newborn healthcare, potential legal issues include informed consent, where patients must be fully informed before medical procedures. Medical malpractice can occur if healthcare providers fail to meet the standard of care. Abandonment is a legal issue if healthcare providers neglect patients after agreeing to provide care. Choosing D is correct because all the mentioned issues are relevant to maternal and newborn healthcare legal concerns.
Which of the following is a potential complication of gestational diabetes?
- A. Hyperglycemia
- B. Hypoglycemia
- C. Polyhydramnios
- D. Hypertension
Correct Answer: C
Rationale: The correct answer is C: Polyhydramnios. Gestational diabetes can lead to increased fetal growth and higher amniotic fluid levels, causing polyhydramnios. This can lead to complications during delivery.
Incorrect choices:
A: Hyperglycemia is a symptom of gestational diabetes, not a complication.
B: Hypoglycemia is not a common complication of gestational diabetes.
D: Hypertension is not directly linked to gestational diabetes complications.