Nokea
A nurse is preparing to administer a tetanus toxoid vaccine to a postpartum person. What is the nurse's priority action before administering the vaccine?
- A. verify the person's immunization history
- B. obtain informed consent
- C. check for signs of an allergic reaction
- D. ensure proper positioning for the vaccine
Correct Answer: D
Rationale: The correct answer is D: ensure proper positioning for the vaccine. It is essential to ensure the person is in the correct position before administering the vaccine to ensure accurate and safe administration. Proper positioning helps prevent injury and ensures the vaccine is administered correctly. Verifying the person's immunization history (choice A) is important but not the priority before administering the vaccine. Informed consent (choice B) should be obtained but is not the priority action in this scenario. Checking for signs of an allergic reaction (choice C) is important but should be done after ensuring proper positioning for the vaccine.
You may also like to solve these questions
A pregnant patient is at 30 weeks gestation and is experiencing dizziness and lightheadedness when standing. What is the nurse's first priority action?
- A. Encourage the patient to drink fluids and rest for 10 minutes.
- B. Instruct the patient to lie flat on her back to restore circulation.
- C. Monitor the patient's blood pressure and check for signs of anemia.
- D. Administer oxygen and prepare for immediate delivery.
Correct Answer: A
Rationale: The correct answer is A: Encourage the patient to drink fluids and rest for 10 minutes. This is the first priority action because dizziness and lightheadedness in a pregnant patient at 30 weeks gestation could be due to orthostatic hypotension, a common issue in pregnancy. Encouraging the patient to drink fluids and rest will help increase blood volume and alleviate symptoms.
Choice B is incorrect because lying flat on her back can worsen symptoms due to supine hypotensive syndrome. Choice C is not the first priority as checking for anemia or monitoring blood pressure should come after addressing immediate symptoms. Choice D is incorrect because immediate delivery is not warranted based on the symptoms described.
A nurse is assessing a postpartum person for signs of postpartum hemorrhage. What is the most common early sign of postpartum hemorrhage?
- A. excessive bleeding
- B. low blood pressure
- C. pale skin
- D. dark red bleeding
Correct Answer: C
Rationale: The correct answer is C: pale skin. This is because the most common early sign of postpartum hemorrhage is hypovolemia, which leads to decreased perfusion and oxygenation of tissues. Pale skin indicates decreased blood flow and oxygen delivery, a key indicator of hypovolemia. Excessive bleeding (choice A) is a symptom, not a sign. Low blood pressure (choice B) is a late sign of postpartum hemorrhage. Dark red bleeding (choice D) may indicate the presence of clots but is not specific to early postpartum hemorrhage.
A nurse is caring for a pregnant patient who is at 40 weeks gestation and reports leaking clear fluid. What is the nurse's priority action?
- A. Check the fetal heart rate and assess the mother's vital signs.
- B. Encourage the patient to go home and rest until contractions begin.
- C. Instruct the patient to monitor fetal movement and call back if the fluid continues to leak.
- D. Call the healthcare provider immediately to report the rupture of membranes.
Correct Answer: D
Rationale: The correct answer is D because the nurse's priority action in this scenario is to report the rupture of membranes to the healthcare provider immediately. This is crucial to ensure timely assessment and management to prevent infection and monitor for potential complications. Checking fetal heart rate and vital signs (A) can be important but not as urgent as reporting the rupture of membranes. Encouraging the patient to go home and rest (B) is inappropriate as leaking clear fluid at 40 weeks gestation may indicate rupture of membranes. Instructing the patient to monitor fetal movement and call back (C) is not sufficient as immediate medical attention is needed in case of ruptured membranes.
A nurse is caring for a postpartum person who is breastfeeding. What is the most appropriate intervention if the person is experiencing nipple pain?
- A. apply warm compresses
- B. apply cold compresses
- C. provide distraction techniques
- D. apply lanolin cream
Correct Answer: B
Rationale: The correct answer is B: apply cold compresses. Cold compresses help reduce inflammation and numb the area, providing pain relief for sore nipples. Warm compresses can worsen pain by increasing blood flow. Distraction techniques do not address the root cause of nipple pain. Lanolin cream is commonly used for nipple pain, but it may not provide immediate relief like cold compresses. Cold compresses are the most appropriate intervention in this situation.
What is the purpose of amniocentesis for a patient hospitalized at 34 weeks of gestation with pregnancy-induced hypertension?
- A. Determine if a metabolic disorder exists.
- B. Identify the sex of the fetus.
- C. Identify abnormal fetal cells.
- D. Determine fetal lung maturity.
Correct Answer: D
Rationale: At 34 weeks, amniocentesis is primarily used to assess fetal lung maturity, which is critical if early delivery is being considered.