Nokea
A nurse is performing a vaginal exam on a client who is in active labor. The nurse notes the umbilical cord protruding through the cervix. Which of the following actions should the nurse take?
- A. Administer oxytocin to the client via intravenous infusion
- B. Apply oxygen at 2 L/min via nasal cannula
- C. Prepare for insertion of an intrauterine pressure catheter
- D. Assist the client into the knee-chest position
Correct Answer: D
Rationale: The nurse should assist the client into the knee-chest position to relieve pressure on the umbilical cord. This position helps to prevent cord compression and improves fetal oxygenation.
You may also like to solve these questions
A nurse is caring for a client who is experiencing urinary incontinence. Which of the following recommendations should the nurse include in the teaching plan for this client?
- A. Drink large amounts of water before bedtime
- B. Perform Kegel exercises regularly
- C. Limit fiber in the diet to avoid bowel irritation
- D. Increase intake of caffeinated and carbonated beverages
Correct Answer: B
Rationale: Kegel exercises help strengthen the pelvic floor muscles, which can improve bladder control and reduce urinary incontinence. The nurse should instruct the client to practice these exercises regularly.
To decrease the incidence of sudden infant death syndrome (SIDS), the parents will position the newborn in a:
- A. Prone position
- B. Supine position
- C. Side-lying position
- D. Semi-fowler's position
Correct Answer: B
Rationale: The safest sleeping position for infants is on their back (supine position). This reduces the risk of sudden infant death syndrome (SIDS), as sleeping in other positions can increase the risk of airway obstruction.
A nurse is developing a plan of care for a newborn who has hyperbilirubinemia and a prescription for phototherapy. Which of the following interventions should the nurse include?
- A. Check the newborn's temperature every 8 hr
- B. Apply moisturizing lotion to the newborn's skin every 4 hr
- C. Give the newborn 1 oz of glucose water every 4 hr
- D. Reposition the newborn every 2 to 3 hr
Correct Answer: D
Rationale: Repositioning the newborn every 2 to 3 hours during phototherapy is important to expose all areas of the skin to light and facilitate the breakdown of bilirubin.
A nurse is assessing a newborn 1 hour after birth. The newborn has acrocyanosis and a heart rate of 130 beats per minute. Which of the following actions should the nurse take?
- A. Place the newborn under a radiant warmer
- B. Apply oxygen
- C. Swaddle the newborn
- D. Reassess the newborn in 1 hour
Correct Answer: D
Rationale: Acrocyanosis, or bluish discoloration of the hands and feet, is a normal finding in newborns in the first few hours after birth. The nurse should continue to monitor the newborn and reassess after some time.
A nurse is caring for a client who is postpartum, has a deep-vein thrombosis, and is receiving heparin therapy via subcutaneous injections. Which of the following actions should the nurse take?
- A. Request a prescription for PRN aspirin from the provider.
- B. Massage the injection site thoroughly following administration.
- C. Instruct the client that they cannot breastfeed while receiving heparin.
- D. Administer the injection in the client's abdomen.
Correct Answer: D
Rationale: The nurse should administer the injection in the abdomen, as this is a common site for subcutaneous heparin administration. Aspirin is contraindicated for clients on heparin due to increased bleeding risk.