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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 an increased risk of infection due to the introduction of bacteria into the uterine cavity. Monitoring the client's temperature is crucial to detect any signs of infection promptly. A sudden spike in temperature could indicate chorioamnionitis, a serious infection that can harm both the mother and the baby. O2 saturation (A), blood pressure (C), and urinary output (D) are important assessments but are not the priority in this situation. Monitoring O2 saturation is essential for fetal well-being but is not directly related to the amniotomy procedure. Blood pressure monitoring is significant for detecting any changes in maternal status, but infection assessment takes precedence in this case. Urinary output is essential for assessing hydration status and kidney function, but infection monitoring is more critical during an amniotomy.
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A nurse is caring for a client who is 1 day postpartum and breastfeeding her newborn. The client reports sore nipples. Which of the following actions should the nurse take?
- A. Instruct the client to wait 4 hr between daytime feedings.
- B. Assess the newborn's latch while breastfeeding.
- C. Have the client limit the length of breastfeeding to 5 min per breast.
- D. Offer supplemental formula between the newborn's feedings.
Correct Answer: B
Rationale: Correct Answer: B
Rationale: Assessing the newborn's latch while breastfeeding is crucial in addressing sore nipples. A poor latch can lead to nipple pain. By ensuring proper latch, the nurse can help alleviate the client's discomfort. Other actions are incorrect:
A: Waiting 4 hr between feedings can lead to engorgement and worsen nipple soreness.
C: Limiting breastfeeding time to 5 min can hinder milk supply and not address the root cause.
D: Offering supplemental formula can interfere with establishing breastfeeding and may not address the latch issue.
A nurse is caring for a client who is at 36 weeks of gestation and has methicillin-resistant Staphylococcus aureus. Which of the following types of isolation precautions should the nurse initiate?
- A. Droplet
- B. Contact
- C. Protective environment
- D. Airborne
Correct Answer: B
Rationale: The correct answer is B: Contact precautions. Methicillin-resistant Staphylococcus aureus (MRSA) is primarily spread through direct contact with contaminated skin or surfaces. Contact precautions involve wearing gloves and gowns when in contact with the client or the client's environment to prevent the spread of the infection. Droplet precautions are used for infections transmitted through respiratory droplets, such as influenza. Protective environment precautions are for immunocompromised clients. Airborne precautions are for infections transmitted through small droplets that stay in the air for long periods, such as tuberculosis. Therefore, the most appropriate precaution for a client with MRSA at 36 weeks of gestation is contact precautions to prevent transmission of the infection through direct contact.
A nurse is assessing a client who is at 6 weeks of gestation and adheres to a vegan diet. Which of the following questions should the nurse ask to assess the client’s dietary intake?
- A. How much protein do you eat in a day?
- B. Are you taking a Vitamin C supplement?
- C. Have you considered eating shellfish?
- D. When was the last time you ate meat?
Correct Answer: A
Rationale: The correct answer is A: How much protein do you eat in a day? This question is important because a vegan diet may lack sufficient protein, which is crucial for fetal development during pregnancy. Protein intake should be monitored to ensure the client is meeting their nutritional needs.
Incorrect choices:
B: Are you taking a Vitamin C supplement? - While Vitamin C is important, assessing protein intake is more critical for a vegan diet.
C: Have you considered eating shellfish? - Shellfish is not suitable for a vegan diet.
D: When was the last time you ate meat? - Irrelevant for a vegan client.
A nurse is preparing to administer an IM injection to a newborn. Which of the following sites should the nurse select?
- A. Vastus lateralis
- B. Dorsogluteal
- C. Deltoid
- D. Rectus femoris
Correct Answer: A
Rationale: The correct answer is A: Vastus lateralis. For newborns, the vastus lateralis muscle is the preferred site for intramuscular injections due to its large muscle mass, minimal nerves and blood vessels, and reduced risk of hitting bone. It is located on the lateral aspect of the thigh and is easily accessible for injections. This site also allows for proper absorption of the medication. The other options are not ideal for newborns: B: Dorsogluteal is not recommended due to the risk of damaging the sciatic nerve, C: Deltoid is typically used for older children and adults, and D: Rectus femoris is not a common site for IM injections in newborns.
A nurse is assessing a client who is postpartum following a cesarean birth. The client states, 'I feel like I have to urinate but I can’t go.' Which of the following actions should the nurse take?
- A. Assist the client to ambulate to the bathroom
- B. Insert an indwelling urinary catheter
- C. Perform a bladder scan to assess for urinary retention
- D. Administer a diuretic
Correct Answer: A
Rationale: Correct Answer: A. Assist the client to ambulate to the bathroom.
Rationale: By assisting the client to ambulate to the bathroom, the nurse is promoting normal physiological functioning. Walking can help stimulate the bladder and promote urination, which is often needed after a cesarean birth due to the effects of anesthesia and limited mobility. It also helps prevent complications like urinary retention or urinary tract infections. Encouraging the client to move also aids in promoting circulation, preventing blood clots, and enhancing overall recovery.
Summary of other choices:
B: Inserting an indwelling catheter should not be the first intervention as it can increase the risk of infection and discomfort.
C: Performing a bladder scan is not necessary as the client's symptoms do not indicate a need for immediate assessment of urine volume.
D: Administering a diuretic is not appropriate without assessing the client's condition further as it may not address the underlying issue and could exacerbate any existing problems.