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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.
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A nurse is performing a newborn assessment and notes a soft, swollen area on the newborn's scalp that does not cross the suture line. Which of the following should the nurse document?
- A. Cephalohematoma
- B. Caput succedaneum
- C. Subdural hematoma
- D. Molding
Correct Answer: A
Rationale: A cephalohematoma is a collection of blood between the periosteum and the skull that does not cross the suture line. It results from trauma during birth and typically resolves on its own.
A nurse is caring for a client who is in labor and has a diagnosis of group B streptococcus Ÿ-hemolytic infection. Which of the following medications should the nurse plan to administer?
- A. Ampicillin
- B. Azithromycin
- C. Ceftriaxone
- D. Acyclovir
Correct Answer: A
Rationale: Ampicillin is the recommended antibiotic for treating group B streptococcus infections in pregnant women during labor to prevent neonatal infection.
A nurse is caring for a client who is 28 weeks pregnant and has preeclampsia. Which of the following is the priority assessment?
- A. Level of consciousness
- B. Deep tendon reflexes
- C. Blood pressure
- D. Urinary output
Correct Answer: C
Rationale: Blood pressure is the priority assessment in clients with preeclampsia because hypertension is the primary symptom of the condition. Elevated blood pressure increases the risk of complications such as eclampsia and placental abruption.
A nurse is providing discharge instructions to parents of a circumcised newborn. To prevent diaper adherence to the penis, what will be recommended to apply during diaper changes?
- A. Baby oil
- B. Antibiotic ointment
- C. Petroleum jelly
- D. Alcohol wipes
Correct Answer: C
Rationale: Petroleum jelly is recommended to prevent the diaper from sticking to the circumcised area, reducing irritation and promoting healing. It should be applied during every diaper change until the site heals.
A nurse is discussing recommendations for daily nutrient intake during pregnancy with a client who is at 10 weeks of gestation. For which of the following nutrients should the nurse instruct the client to increase intake during pregnancy?
- A. Vitamin E
- B. Vitamin D
- C. Fiber
- D. Calcium
Correct Answer: D
Rationale: Calcium is vital during pregnancy for fetal bone development and to prevent maternal bone loss. The recommended daily intake should be increased to support these needs.