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The nurse is caring for a client in labor receiving epidural anesthesia. What is the priority nursing assessment?
- A. Assess for bladder distention.
- B. Monitor maternal blood pressure.
- C. Evaluate fetal heart rate.
- D. Check for pain relief.
Correct Answer: B
Rationale: Maternal blood pressure monitoring is essential to detect and manage hypotension, a common side effect of epidural anesthesia.
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The nurse is describing different types of abruptio placenta to a group of students explaining that the incomplete abruptio placenta is
- A. There is massive bleeding in the presence of almost total separation
- B. Separation beginning at the periphery of the placenta
- C. The placenta separates centrally and there can be concealed bleeding
- D. Blood passes between the fetal membrane of the uterine wall and is skipped vaginally
Correct Answer: B
Rationale: In incomplete abruptio placenta, the separation begins at the periphery of the placenta. This results in partial detachment of the placenta from the uterine wall, rather than almost total separation as seen in complete abruptio placenta. This type of abruptio placenta may present with vaginal bleeding depending on the extent of separation and may lead to various degrees of maternal and fetal compromise.
The nurse is educating a client about kick counts. What instruction is most appropriate?
- A. Perform kick counts once a week.
- B. Lie on your back to count fetal movements.
- C. Count 10 fetal movements over 2 hours.
- D. Start counting movements at 36 weeks.
Correct Answer: C
Rationale: Counting 10 fetal movements within 2 hours is a standard method to monitor fetal well-being.
The nurse is educating a client about signs of preterm labor. What symptom should be reported immediately?
- A. Frequent urination.
- B. Low back pain and cramping.
- C. Increased appetite.
- D. Braxton Hicks contractions.
Correct Answer: B
Rationale: Low back pain and cramping can indicate preterm labor and should be reported immediately for further evaluation.
The nurse is performing Leopold's maneuvers on a client in labor. What is the primary purpose of this assessment?
- A. Evaluate fetal heart rate.
- B. Determine fetal position and presentation.
- C. Check for uterine contractions.
- D. Assess amniotic fluid volume.
Correct Answer: B
Rationale: Leopold's maneuvers help identify fetal position, presentation, and engagement for labor management.
How should a nurse respond to a mother asking about newborn hearing screening?
- A. Explain that hearing screening is optional
- B. Reassure the mother that this is a routine test
- C. Inform the mother that hearing screening is mandatory
- D. Provide resources for further testing if needed
Correct Answer: B
Rationale: Hearing screening is a routine test to identify hearing issues early and ensure proper interventions.