Nokea
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: Leopold maneuvers should be performed in the following sequence: palpate the fundus, determine the location of the fetal back, palpate for the fetal part presenting at the inlet, and identify the attitude of the head.
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Which of the following is a potential complication of gestational hypertension?
- A. Preterm labor
- B. Fetal growth restriction
- C. Placental abruption
- D. All of the above
Correct Answer: D
Rationale: Gestational hypertension can lead to preterm labor, fetal growth restriction, and placental abruption.
What is the recommended method of feeding for a term infant?
- A. Breastfeeding
- B. Formula feeding
- C. Bottle feeding with breast milk
- D. Parenteral nutrition
Correct Answer: A
Rationale: Breastfeeding is the recommended method for a term infant due to its numerous benefits, such as providing essential nutrients, antibodies, and promoting bonding. Breast milk is easily digestible and tailored to the baby's needs, reducing the risk of infections and allergies. It also supports the infant's optimal growth and development. Formula feeding, while a valid alternative, lacks the same level of antibodies and nutrients found in breast milk. Bottle feeding with breast milk is a suitable option if direct breastfeeding is not possible. Parenteral nutrition, on the other hand, is an intravenous method used for infants with specific medical needs and is not the recommended standard method of feeding for healthy term infants.
A nurse is caring for a client who is 12 hr postpartum and has a fourth-degree laceration of the perineum. Which of the following actions should the nurse take?
- A. Apply a moist, warm compress to the perineum.
- B. Provide the client with a cool sitz bath.
- C. Administer methylergonovine 0.2 mg IM.
- D. Apply povidone-iodine to the client’s perineum after she voids.
Correct Answer: A
Rationale: The correct answer is A: Apply a moist, warm compress to the perineum. This action helps to promote healing and reduce discomfort for the client with a fourth-degree perineal laceration. Warmth can increase blood flow to the area, aiding in the healing process. Moisture can also help with wound healing and provide comfort.
Choice B is incorrect as a cool sitz bath may not be suitable for a fourth-degree laceration as it can cause vasoconstriction and slow down the healing process. Choice C, administering methylergonovine, is not indicated for perineal lacerations. Choice D, applying povidone-iodine after voiding, can be irritating to the wound and delay healing.
In summary, applying a warm, moist compress is the best option to promote healing and comfort for the client with a fourth-degree perineal laceration.
A nurse is assessing a newborn following a circumcision. Which of the following findings should the nurse identify as an indication that the newborn is experiencing pain?
- A. Decreased heart rate.
- B. Chin quivering.
- C. Pinpoint pupils.
- D. Slowed respirations.
Correct Answer: B
Rationale: Chin quivering is a sign of pain in newborns and should be addressed with appropriate pain management interventions.
Which of the following is a potential complication of a postpartum hemorrhage?
- A. Disseminated intravascular coagulation (DIC)
- B. Anemia
- C. Hyperglycemia
- D. All of the above
Correct Answer: A
Rationale: Postpartum hemorrhage can lead to disseminated intravascular coagulation (DIC), a serious condition where blood clotting is disrupted.