Nokea
A nurse is caring for a client who is in the second stage of labor. Which of the following manifestations should the nurse expect?
- A. The client expels the placenta
- B. The client experiences gradual dilation of the cervix
- C. The client begins have regular contractions.
- D. The client delivers the newborn
Correct Answer: D
Rationale: The correct answer is D. In the second stage of labor, the client delivers the newborn. This stage begins with full dilation of the cervix and ends with the birth of the baby. The expulsion of the placenta (Choice A) occurs in the third stage of labor. Gradual dilation of the cervix (Choice B) is characteristic of the first stage of labor. Regular contractions (Choice C) may occur throughout labor but are not specific to the second stage. So, the correct answer is D because it aligns with the chronological progression of labor stages.
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A nurse is providing discharge teaching to a new parent about car seat safety. Which of the following statements by the parent indicates an understanding of the teaching?
- A. “I should position my baby’s car seat at a 45-degree angle in the car.”
- B. “I should place the car seat rear facing until my baby is 12 months old.”
- C. “I should place the harness snugly in a slot above my baby’s shoulders.”
- D. “I should position the retainer clip at the top of my baby’s abdomen.”
Correct Answer: A
Rationale: The correct answer is A because positioning the baby's car seat at a 45-degree angle helps prevent the baby's head from slumping forward, ensuring proper airway and breathing. Placing the car seat rear facing until 12 months old is recommended for optimal safety. Option C is incorrect as the harness should be at or below the baby's shoulders. Option D is incorrect as the retainer clip should be positioned at armpit level for proper safety.
A nurse is using Nagele's rule to calculate the expected delivery date of a client who reports the first day of the last menstrual cycle was July 28th. Which of the following dates should the nurse document as the client's expected delivery date?
- A. April 21st
- B. April 4th
- C. May 5th
- D. May 21st
Correct Answer: C
Rationale: The correct answer is C: May 5th. Nagele's rule is used to estimate the expected delivery date by adding 7 days to the first day of the last menstrual cycle, subtracting 3 months, and then adding 1 year. In this case, the first day of the last menstrual cycle was July 28th. Adding 7 days gives August 4th. Subtracting 3 months gives May 4th. Adding 1 year gives May 4th of the next year. Since May 4th falls on a Sunday, the expected delivery date is adjusted to the following day, May 5th. Choice A, B, and D are incorrect because they do not follow the correct calculations of Nagele's rule.
A nurse is caring for a newborn who is 6 hr old and has a bedside glucometer reading of 65 mg/ dL. The newborn’s mother has type 2 diabetes mellitus. Which of the following actions should the nurse take?
- A. Obtain a blood sample for a serum glucose level
- B. Feed the newborn immediately
- C. Administer 50 mL of dextrose solution IV
- D. Reassess the blood glucose level prior to the next feeding
Correct Answer: B
Rationale: The correct answer is B: Feed the newborn immediately. In this scenario, the newborn's low blood glucose level may be due to inadequate glycogen stores from the mother's diabetes. Feeding the newborn will help increase their blood glucose levels naturally. Other choices are incorrect because: A: Obtaining a blood sample for a serum glucose level delays immediate action. C: Administering dextrose solution IV is an invasive intervention that should be reserved for severe cases. D: Reassessing the blood glucose level is important but should not delay feeding in this critical situation. E, F, G: No information given.
The nurse is teaching a client and her partner about the technique of counter pressure during labor. Which of the following statements by the nurse is appropriate?
- A. Your partner will apply upward pressure on your lower abdomen between contractions
- B. Your partner will apply continuous firm pressure between your thumb and index finger
- C. Your partner will apply pressure to the top of your uterus during contractions
- D. Your partner will apply steady pressure with a tennis ball to your lower back
Correct Answer: D
Rationale: The correct answer is D because counter pressure is typically applied to the lower back to help alleviate back pain during labor contractions. This technique can help relieve discomfort by stimulating pressure receptors and distracting from the pain of contractions. Choice A is incorrect as upward pressure on the lower abdomen is not the standard technique for counter pressure. Choice B is incorrect as applying pressure between the thumb and index finger is not relevant to counter pressure. Choice C is incorrect as pressure should be applied to the lower back, not the top of the uterus, during contractions.
A nurse is caring for a client who has a complete uterine rupture. Which of the following findings should the nurse expect?
- A. Early fetal heart rate decelerations
- B. Hypotension
- C. Painless, dark red vaginal bleeding
- D. bounding peripheral pulses
Correct Answer: B
Rationale: The correct answer is B: Hypotension. A complete uterine rupture is a serious complication where the uterine wall tears completely, leading to massive internal bleeding. This can result in hypotension due to blood loss. Early fetal heart rate decelerations (choice A) are not indicative of uterine rupture. Painless, dark red vaginal bleeding (choice C) is more commonly associated with placental abruption. Bounding peripheral pulses (choice D) are not a typical finding in uterine rupture.