Nokea
A nurse is obtaining a 2-hr postprandial blood glucose from a client. Which of the following actions should the nurse take?
- A. Puncture the finger while still damp with antiseptic solution.
- B. Smear the blood onto the reagent strip.
- C. Hold the finger above the heart prior to puncture.
- D. Select the lateral side of the finger for puncture.
Correct Answer: D
Rationale: The correct answer is D: Select the lateral side of the finger for puncture. This choice is correct because the lateral side of the finger has fewer nerve endings, making it less painful for the client. It also minimizes the risk of injury to the client and provides an adequate blood sample for testing.
Explanation for other choices:
A: Puncturing the finger while still damp with antiseptic solution can dilute the blood sample, leading to inaccurate results.
B: Smearing the blood onto the reagent strip can cause contamination and inaccurate readings.
C: Holding the finger above the heart prior to puncture can lead to increased blood flow and affect the accuracy of the blood glucose reading.
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A nurse is assessing a client who gave birth vaginally 12 hr ago and palpates their uterus to the right above the umbilicus. Which of the following interventions should the nurse perform?
- A. Reassess the client in 2 hr.
- B. Administer simethicone.
- C. Assist the client to empty their bladder.
- D. Instruct the client to lie on their right side.
Correct Answer: C
Rationale: The correct answer is C: Assist the client to empty their bladder. Palpating the uterus above the umbilicus indicates uterine atony, a common cause of postpartum hemorrhage. A full bladder can displace the uterus further, exacerbating the risk of hemorrhage. Emptying the bladder will allow the uterus to contract properly and reduce the risk. Reassessing the client in 2 hours (A) delays immediate intervention. Administering simethicone (B) is for gas relief and not relevant in this situation. Instructing the client to lie on their right side (D) does not address the underlying issue of uterine atony.
A nurse is preparing to perform Leopold maneuvers for a client. Identify the sequence the nurse should follow.
- A. Palpate the fundus to identify the fetal part.
- B. Determine the location of the fetal back.
- C. Palpate for the fetal part presenting at the inlet.
- D. Identify the attitude of the head.
Correct Answer: A,B,CD
Rationale: The correct sequence for performing Leopold maneuvers is A, B, C, and D. Firstly, palpating the fundus to identify the fetal part helps determine the position of the baby in the uterus. Secondly, determining the location of the fetal back provides information on the baby's position relative to the mother's spine. Thirdly, palpating for the fetal part presenting at the inlet helps identify which part of the baby is entering the birth canal. Lastly, identifying the attitude of the head gives insight into how the baby is positioned within the pelvis for delivery. This sequential approach allows for a systematic assessment of fetal position and presentation. The other choices are incorrect as they do not follow the correct order of Leopold maneuvers, which can lead to inaccurate assessment and potential complications during labor and delivery.
A nurse is assessing a newborn who is 16 hr old. Which of the following findings should the nurse report to the provider?
- A. Substernal retractions
- B. Acrocyanosis
- C. Overlapping suture lines
- D. Head circumference 33 cm (13 in)
Correct Answer: A
Rationale: The correct answer is A: Substernal retractions. Substernal retractions in a newborn indicate respiratory distress and can be a sign of a serious issue such as respiratory distress syndrome. This finding requires immediate attention from the provider to assess and manage the newborn's respiratory status. Acrocyanosis (B) is a common finding in newborns and is not typically concerning. Overlapping suture lines (C) can be normal in newborns due to molding during birth. A head circumference of 33 cm (13 in) (D) falls within the normal range for a newborn and does not require immediate reporting.
A nurse is reviewing the medical record of a client who had a vaginal delivery 3 hr ago. Which of the following findings place the client at risk for postpartum hemorrhage? (Select all that apply.)
- A. Labor induction with oxytocin
- B. Newborn weight 2.948 kg (6 lb 8 oz)
- C. Vacuum-assisted delivery
- D. History of uterine atony
- E. History of human papillomavirus
Correct Answer: A,C,D
Rationale: The correct answers are A, C, and D.
A: Labor induction with oxytocin can lead to uterine hyperstimulation, increasing the risk of postpartum hemorrhage.
C: Vacuum-assisted delivery can cause trauma to the birth canal, leading to increased bleeding.
D: History of uterine atony indicates a potential inability of the uterus to contract effectively, increasing the risk of postpartum hemorrhage.
B: Newborn weight and history of human papillomavirus are not directly related to postpartum hemorrhage.
A nurse is teaching a client who is at 10 weeks of gestation about nutrition during pregnancy. Which of the following statements by the client indicates an understanding of the teaching?
- A. "I should increase my protein intake to 60 grams each day."
- B. "I should drink 2 liters of water each day."
- C. "I should increase my overall daily caloric intake by 300 calories."
- D. "I should take 600 micrograms of folic acid each day."
Correct Answer: A
Rationale: The correct answer is A: "I should increase my protein intake to 60 grams each day." This is because protein is essential for the growth and development of the fetus. During pregnancy, the recommended daily protein intake increases to support the baby's growth. Adequate protein intake also helps prevent complications such as low birth weight. Increasing protein to 60 grams per day is a specific and appropriate guideline for a client at 10 weeks of gestation.
Choice B is incorrect as hydration is important, but the specific amount of 2 liters per day is not necessarily tailored to the client's needs.
Choice C is incorrect as the increase in caloric intake during pregnancy is typically around 300-500 calories per day, not a fixed 300 calories for all individuals.
Choice D is incorrect as the recommended daily intake of folic acid during pregnancy is 400-800 micrograms, not a fixed amount of 600 micrograms. It is important for neural tube development in the fetus.