Nokea
A nurse is preparing to perform Leopold maneuvers on a client who is at 36 weeks of gestation. Identify the sequence of actions the nurse should take.
- A. Instruct the client to empty their bladder.
- B. Position the client supine with knees flexed and place a small, rolled towel under one of their hips.
- C. Palpate the fetal part positioned in the fundus.
- D. Palpate the fetal parts along both sides of the uterus.
Correct Answer: A, B, C, D
Rationale: The correct order is A, B, C, D. First, instructing the client to empty their bladder ensures better visualization and palpation of the uterus. Second, positioning the client supine with knees flexed and a small towel under the hip optimizes comfort and facilitates proper examination. Third, palpating the fetal part in the fundus helps determine the fetal presentation. Finally, palpating the fetal parts along both sides of the uterus assists in identifying the position and engagement of the fetus. Choices E, F, and G are not relevant to the Leopold maneuvers sequence and do not contribute to the accurate assessment of fetal position and presentation.
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Which of the following is a potential ethical issue related to pain management in maternal and newborn healthcare?
- A. Undertreatment of pain
- B. Overtreatment of pain
- C. Use of alternative therapies without informed consent
- D. All of the above
Correct Answer: D
Rationale: The correct answer is D: All of the above. Undertreatment of pain can lead to unnecessary suffering, while overtreatment can result in adverse effects for the mother and newborn. Additionally, using alternative therapies without informed consent violates the principle of autonomy. These issues highlight the importance of balancing pain management strategies to ensure optimal care and ethical practice in maternal and newborn healthcare. Choices A, B, and C each represent distinct ethical concerns that may arise in pain management, emphasizing the need for a comprehensive approach to address these complexities.
Which of the following is a potential complication of gestational diabetes?
- A. Polyhydramnios
- B. Preterm labor
- C. Neonatal hypoglycemia
- D. All of the above
Correct Answer: D
Rationale: Gestational diabetes can lead to polyhydramnios, preterm labor, and neonatal hypoglycemia.
A nurse is preparing to administer oxytocin to a client who is postpartum. Which of the following findings is an indication for the administration of the medication? (Select all that apply.)
- A. Flaccid uterus
- B. Cervical laceration
- C. Excess vaginal bleeding
- D. Increased afterbirth cramping
Correct Answer: A,C
Rationale: The correct answers are A and C. A flaccid uterus indicates poor uterine tone, which can lead to postpartum hemorrhage. Oxytocin is given to enhance uterine contractions and tone, helping prevent excessive bleeding. Excess vaginal bleeding is also an indication for oxytocin administration as it can help control bleeding by promoting uterine contractions. Choices B, D, and other options are incorrect as they do not directly relate to the need for oxytocin administration in this scenario. Cervical laceration and increased afterbirth cramping may require other interventions, but they do not specifically indicate the need for oxytocin administration to address postpartum bleeding.
A nurse is caring for a client who is 12 hr postpartum and has a third-degree perineal laceration. The client reports not having a bowel movement for 4 days. Which of the following medications should the nurse administer?
- A. Bisacodyl 10 mg rectal suppository
- B. Magnesium hydroxide 30 mL PO
- C. Famotidine 20 mg PO
- D. Loperamide 4 mg PO
Correct Answer: A
Rationale: A rectal suppository like bisacodyl is appropriate for relieving constipation in a postpartum client with a perineal laceration, as it avoids straining. Loperamide is an antidiarrheal and not indicated here.
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: Ensuring that the parent's identification band number matches the newborn's identification band number is a critical safety measure to prevent errors in newborn identification.