Nokea
A nurse is caring for a client who is postpartum and experiencing hypovolemic shock. Which of the following findings should the nurse expect?
- A. Cool, Clammy skin
- B. Respiratory rate 18/min
- C. Bounding pulses
- D. Urinary output 30 mL/hr
Correct Answer: A
Rationale: Cool, clammy skin results from vasoconstriction in hypovolemic shock, unlike normal respiratory rate, bounding pulses (compensatory tachycardia typical), or low-normal urine output.
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A nurse is providing teaching to a client who is primigravid and is scheduled to have an abdominal ultrasound. Which of the following statements by the client indicates an understanding of the teaching?
- A. I won't apply perfumed lotion to my abdomen before the test.
- B. I can't have anything to eat after midnight.
- C. I need to take a stool softener the night before the test.
- D. I will drink water before the test until my bladder feels full.
Correct Answer: D
Rationale: A full bladder enhances ultrasound visibility by displacing intestines, unlike avoiding lotion, fasting, or stool softeners, which are not required.
A nurse is caring for a client who is in labor and just received epidural anesthesia. The client's blood pressure is 90/50 mm Hg. Which of the following actions should the nurse take?
- A. Turn the client onto their side
- B. Initiate an amnioinfusion for the client
- C. Administer naloxone to the client
- D. Monitor the client's blood pressure every 15 min
Correct Answer: A
Rationale: Turning the client to their side improves uterine blood flow, addressing epidural-induced hypotension, unlike amnioinfusion, naloxone (irrelevant), or monitoring alone.
A nurse is performing an assessment of a newborn's Babinski reflex. Which of the following findings should the nurse expect?
- A. Eversion of the great toe
- B. Flexion of the forearm
- C. The downward curl of the toes
- D. Extension of the leg
Correct Answer: A
Rationale: A positive Babinski reflex in newborns shows dorsiflexion and fanning of toes, unlike forearm flexion, toe curling, or leg extension.
A nurse is assessing the results of a nonstress test for an antepartum client at 35 weeks of gestation. Which of the following findings should indicate to the nurse the need for further diagnostic testing?
- A. Three fetal movements perceived by the client in a 20 min testing period
- B. No late decelerations in the fetal heart rate noted with three uterine contractions of 60 seconds in duration within a 10-min resting period
- C. An increase in fetal heart rate to 150/min above the baseline of 140/min lasting 10 seconds in response to fetal movement within a 40-min testing period
- D. Irregular contractions of 10 to 20 seconds in duration that are not felt by the client
Correct Answer: A
Rationale: Only three fetal movements in 20 minutes is below the expected activity level, suggesting possible fetal compromise, unlike reassuring heart rate responses or minor contractions.
A nurse is reviewing the electronic medical record of a postpartum client. The nurse should identify that which of the following factors places the client at risk for an infection?
- A. Midline episiotomy
- B. Meconium-stained fluid
- C. Gestational hypertension
- D. Placenta previa
Correct Answer: B
Rationale: Meconium-stained fluid increases maternal infection risk if it enters the bloodstream, unlike episiotomy (managed risk), hypertension, or previa (other complications).