Nokea
A nurse is providing education to a client who is 28 weeks pregnant and at risk for preterm labor. Which of the following signs should the nurse instruct the client to report immediately?
- A. Lower back pain
- B. Shortness of breath
- C. Decreased fetal movement
- D. Nausea and vomiting
Correct Answer: A
Rationale: Lower back pain, especially if accompanied by uterine contractions or pressure, can be a sign of preterm labor. The client should report this immediately to prevent complications or early delivery.
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A nurse is caring for a client in active labor. The nurse notes variable decelerations in the fetal heart rate. Which of the following is the priority nursing action?
- A. Administer oxygen
- B. Reposition the client
- C. Prepare for delivery
- D. Increase IV fluids
Correct Answer: B
Rationale: Variable decelerations are often caused by umbilical cord compression. Repositioning the client can help alleviate pressure on the cord and improve fetal oxygenation.
A nurse on a postpartum unit is receiving change-of-shift report for four clients. Which of the following clients should the nurse see first?
- A. A client who gave birth 1 day ago and needs Rho(D) immune globulin
- B. A client who gave birth 3 days ago and reports breast fullness
- C. A client who gave birth 12 hr ago and reports an increase in urinary output
- D. A client who gave birth 8 hr ago and is saturating a perineal pad every hour
Correct Answer: D
Rationale: The client saturating a perineal pad every hour may be experiencing postpartum hemorrhage, which is a medical emergency requiring immediate assessment and intervention.
Following delivery, the nurse places the newborn under a radiant heat warmer. Which of the following is this action used to prevent?
- A. Cold stress
- B. Hyperthermia
- C. Dehydration
- D. Hypoxia
Correct Answer: A
Rationale: Cold stress in newborns can lead to increased oxygen consumption and energy expenditure as the body tries to maintain its temperature. This can result in hypoglycemia and metabolic acidosis if not addressed. The use of a radiant warmer helps maintain the infant's body temperature, reducing the risk of cold stress and its complications.
A client is being treated with eclampsia. What is a priority nursing intervention?
- A. Assess for hyperreflexia
- B. Administer oxygen
- C. Monitor blood pressure every 15 minutes
- D. Prepare for delivery
Correct Answer: A
Rationale: Eclampsia is a serious complication of pregnancy characterized by seizures. Hyperreflexia is often a precursor to eclampsia, and assessing for it can help predict and manage the condition before seizures occur.
A nurse is performing a vaginal exam on a client who is in active labor. The nurse notes the umbilical cord protruding through the cervix. Which of the following actions should the nurse take?
- A. Administer oxytocin to the client via intravenous infusion
- B. Apply oxygen at 2 L/min via nasal cannula
- C. Prepare for insertion of an intrauterine pressure catheter
- D. Assist the client into the knee-chest position
Correct Answer: D
Rationale: The nurse should assist the client into the knee-chest position to relieve pressure on the umbilical cord. This position helps to prevent cord compression and improves fetal oxygenation.