RN Maternal Newborn Online Practice 2019 A

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A nurse is caring for a client who is in the first stage of labor. The nurse observes the umbilical cord protruding from the vagina. Which of the following actions should the nurse perform first?

  • A. Cover the cord with a sterile, moist saline dressing.
  • B. Prepare the client for an immediate birth.
  • C. Place the client in knee-chest position.
  • D. Insert a gloved hand into the vagina to relieve pressure on the cord. Rationale: This is the first nursing action because it is essential to prevent any pressure on the umbilical cord to promote oxygenation of the fetus.
Correct Answer: D

Rationale: The correct action for the nurse to perform first when observing the umbilical cord protruding from the vagina during the first stage of labor is to insert a gloved hand into the vagina to relieve pressure on the cord. This is crucial to prevent compression of the cord, which could compromise oxygenation to the fetus. By gently lifting the presenting part off the cord, the nurse can help maintain blood flow and prevent fetal distress. Once the pressure on the cord is relieved, additional interventions such as preparing the client for immediate birth, covering the cord with a sterile, moist saline dressing, or positioning the client in knee-chest position may be necessary depending on the clinical situation. But the priority is to relieve pressure on the umbilical cord promptly to ensure the well-being of the fetus.

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A client at 36 weeks' gestation reports decreased fetal movement. What is the nurse's priority action?

  • A. Perform a nonstress test.
  • B. Encourage the client to drink orange juice.
  • C. Schedule an ultrasound.
  • D. Notify the healthcare provider.
Correct Answer: A

Rationale: A nonstress test evaluates fetal well-being and is the first step in assessing decreased fetal movement.

A nurse is caring for a client who is 4hr postpartum and is experiencing hypovolemic shock. Which of the following actions should the nurse take?

  • A. Administer indomethacin
  • B. Insert a second using a 22-gauge IV catheter.
  • C. Insert an indwelling urinary catheter.
  • D. Administer oxygen at 4L/min via nasal cannula.
Correct Answer: B

Rationale: The priority action for a client experiencing hypovolemic shock is to restore circulating volume. Inserting a second IV using a 22-gauge catheter would allow for rapid administration of IV fluids to help restore blood volume and improve circulation. This intervention is crucial in managing hypovolemic shock to prevent further complications and stabilize the client's condition. Administering indomethacin, inserting an indwelling urinary catheter, or administering oxygen, while potentially necessary in some cases, are not the immediate priority in managing hypovolemic shock.

Be- tions before finding one that works.

  • A. Once you take the prescribed medication, you plan on teaching this client? will be cured of the infection.
  • B. Breastfeeding
  • C. Even though you don't experience symptoms,
  • D. Postpartum depression you can still spread the infection.
Correct Answer: C

Rationale: Option C is the most appropriate statement to make to the client because it addresses the reality of sexually transmitted infections (STIs). Many STIs can be transmitted even when the infected individual is not experiencing any symptoms. This is an important point to communicate to prevent the spread of the infection to other sexual partners. It emphasizes the need for practicing safe sex measures and getting tested regularly, regardless of the presence of symptoms. It is important for the client to understand that they can still be a carrier of the infection even if they are not displaying any noticeable symptoms.

A client in labor is receiving epidural anesthesia. What is the priority nursing intervention?

  • A. Monitor maternal heart rate.
  • B. Assess for bladder distention.
  • C. Check maternal blood pressure frequently.
  • D. Encourage frequent position changes.
Correct Answer: C

Rationale: Frequent monitoring of maternal blood pressure is essential to detect and manage hypotension caused by epidural anesthesia.

A nurse on the postpartum unit is caring for four clients. For which of the following clients should the nurse notify the provider?

  • A. A client who has a urinary output of 300 ml in 8 hr.
  • B. A client who reports abdominal cramping during breastfeeding
  • C. A client who is receiving magnesium sulfate and has absent deep tendon reflexes
  • D. A client who reports lochia rubra requiring changing perineal pads every 3 hr.
Correct Answer: C

Rationale: The nurse should notify the provider for the client who is receiving magnesium sulfate and has absent deep tendon reflexes. Absent deep tendon reflexes are a sign of magnesium toxicity, which can lead to serious complications such as respiratory depression, cardiac arrest, and death. Prompt intervention by the provider is necessary to adjust the magnesium sulfate dosage and prevent further harm to the client.

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