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A nurse is planning care for a client who is in labor and is to have an amniotomy. Which of the following assessments should the nurse identify as the priority?
- A. O2 saturation.
- B. Temperature.
- C. Blood pressure.
- D. Urinary output.
Correct Answer: B
Rationale: The correct answer is B: Temperature. During an amniotomy, there is a risk of infection due to the introduction of bacteria into the amniotic fluid. Monitoring the client's temperature is crucial as an elevated temperature could indicate infection, which can be life-threatening for both the mother and the fetus. O2 saturation (A), blood pressure (C), and urinary output (D) are important assessments but not the priority in this situation. O2 saturation is typically monitored continuously during labor, blood pressure can fluctuate during labor but is not directly impacted by amniotomy, and urinary output is important for assessing hydration status but does not take precedence over monitoring for infection.
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A nurse is transporting a newborn back to the parent's room following a procedure. Which of the following actions should the nurse take prior to leaving the newborn with their parent?
- A. Ensure that the parent's identification band number matches the newborn's identification band number.
- B. Ask the parent to verify their name and date of birth.
- C. Check the newborn's security tag number to ensure it matches the newborn's medical record.
- D. Match the newborn's date and time of birth to the information in the parent's medical record.
Correct Answer: A
Rationale: Correct Answer: A
Rationale: Ensuring that the parent's identification band number matches the newborn's identification band number is crucial for accurate identification. This step confirms that the parent is indeed the rightful guardian of the newborn, preventing mix-ups and ensuring the newborn's safety. Verifying the parent's identity through their name and date of birth (Option B) is helpful but not as reliable as matching identification band numbers. Checking the newborn's security tag number (Option C) is important for hospital security but does not directly verify the parent's identity. Matching the newborn's date and time of birth to the information in the parent's medical record (Option D) is not as specific and reliable as matching identification band numbers.
A nurse is reviewing the medical record of a newly admitted client who is at 32 weeks of gestation. Which of the following conditions is an indication for fetal assessment using electronic fetal monitoring?
- A. Oligohydramnios.
- B. Hyperemesis gravidarum.
- C. Leukorrhea.
- D. Periodic tingling of the fingers.
Correct Answer: A
Rationale: The correct answer is A: Oligohydramnios. Electronic fetal monitoring is indicated for assessing fetal well-being in pregnancies with conditions that may compromise fetal oxygenation, such as oligohydramnios. Oligohydramnios is a condition where there is an insufficient amount of amniotic fluid around the fetus, which can lead to fetal distress. Electronic fetal monitoring helps track the fetal heart rate and uterine contractions to detect signs of distress. Hyperemesis gravidarum (B), leukorrhea (C), and periodic tingling of the fingers (D) are not indications for fetal monitoring as they do not directly impact fetal well-being.
A nurse is providing teaching for a client who has a new prescription for combined oral contraceptives. Which of the following findings should the nurse include as an adverse effect of this medication?
- A. Depression.
- B. Polyuria.
- C. Hypotension.
- D. Urticaria.
Correct Answer: A
Rationale: The correct answer is A: Depression. Combined oral contraceptives can lead to mood changes, including depression, as a potential adverse effect due to hormonal fluctuations. This is important for the nurse to include in teaching to monitor and address any mental health concerns. Polyuria (increased urination) is not a common adverse effect of combined oral contraceptives. Hypotension (low blood pressure) is not typically associated with this medication. Urticaria (hives) is more commonly seen with allergic reactions rather than as a side effect of oral contraceptives.
A nurse is preparing to perform Leopold maneuvers for a client. Identify the sequence the nurse should follow. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
- A. Identify the attitude of the head.
- B. Palpate the fundus to identify the fetal part.
- C. Determine the location of the fetal back.
- D. Palpate for the fetal part presenting at the inlet.
Correct Answer: B, C, D, A
Rationale: The correct order for performing Leopold maneuvers is B, C, D, A. Firstly, palpating the fundus (B) helps determine the fetal part. Next, determining the location of the fetal back (C) guides the nurse to find the fetal back. Palpating for the fetal part at the inlet (D) helps identify its presentation. Lastly, identifying the attitude of the head (A) completes the assessment. Other choices are not relevant to the sequential assessment in Leopold maneuvers.
A nurse is admitting a client to the labor and delivery unit when the client states, 'My water just broke.' Which of the following interventions is the nurse's priority?
- A. Perform Nitrazine testing.
- B. Assess the fluid.
- C. Check cervical dilation.
- D. Begin FHR monitoring.
Correct Answer: D
Rationale: The correct answer is D: Begin FHR monitoring. This is the priority intervention because it assesses the well-being of the fetus immediately after the client's water breaking. Monitoring the fetal heart rate can provide crucial information on the baby's status and help identify any signs of distress. Performing Nitrazine testing (A) or checking cervical dilation (C) can be done after ensuring fetal well-being. Assessing the fluid (B) can confirm if the amniotic sac has indeed ruptured but does not provide immediate information on fetal status.