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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: The correct answer is A: Ensure that the parent's identification band number matches the newborn's identification band number. This is crucial for proper identification and prevention of mix-ups. Matching the identification bands ensures that the newborn is going to the correct parent, enhancing safety.
Choice B is incorrect because asking the parent to verify their own information does not confirm the identification of the newborn. Choice C is incorrect as it focuses on the security tag number, which may not be as reliable as the identification bands. Choice D is incorrect as matching the date and time of birth to the parent's medical record does not provide direct confirmation of the parent-newborn match.
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A nurse is caring for a client who becomes unresponsive upon delivery of the placenta. Which of the following actions should the nurse take first?
- A. Determine respiratory function.
- B. Increase the IV fluid rate.
- C. Access emergency medications from the cart.
- D. Collect a maternal blood sample for coagulopathy studies.
Correct Answer: A
Rationale: The correct answer is A: Determine respiratory function. This is the priority because an unresponsive client may be experiencing respiratory distress, which can quickly lead to hypoxia and cardiac arrest. Assessing respiratory function allows the nurse to intervene promptly if needed. Increasing IV fluid rate (B) is important but not the first priority. Accessing emergency medications (C) may be necessary, but addressing respiratory status comes first. Collecting a blood sample for coagulopathy studies (D) is important for assessing bleeding disorders but is not the immediate priority in this situation.
A nurse is reviewing the provider's prescription in the adolescent's
medical chart.
Exhibit 1
History and Physical
Adolescent is sexually active with two current partners.
IUD in place
Reports not using condoms during sexual activity.
History of type 1 diabetes mellitus
The nurse is reviewing the provider's prescriptions in the adolescent's medical chart.Complete the following sentence by using the list of options. The nurse should first implement ---------------------- and ---------------------------------
- A. Providing education on medications
- B. Administering ceftriaxone
- C. Administering metronidazole and educating on condom use
Correct Answer: A,B
Rationale: The correct answer is A,B. First, providing education on medications is crucial to ensure the adolescent understands the prescribed treatment. This empowers them to adhere to the regimen, promoting better health outcomes. Second, administering ceftriaxone aligns with the provider's prescription and is a direct action the nurse must take to carry out the treatment plan. Choices C, D, E, F, and G are incorrect because administering metronidazole and educating on condom use (C) is not the immediate priority. Administering metronidazole is not mentioned in the provider's prescriptions, so it is not the first step. Choices D, E, F, and G are irrelevant and not related to the provider's prescriptions or the adolescent's care.
A nurse is caring for a client who is at 38 weeks of gestation. Which of the following actions should the nurse take prior to applying an external transducer for fetal monitoring?
- A. Determine progression of dilatation and effacement.
- B. Perform Leopold maneuvers.
- C. Complete a sterile speculum exam.
- D. Prepare a Nitrazine paper test.
Correct Answer: B
Rationale: The correct answer is B: Perform Leopold maneuvers. Before applying an external transducer for fetal monitoring at 38 weeks of gestation, the nurse should perform Leopold maneuvers to determine the fetal position, presentation, and lie. This helps in correctly placing the transducer over the fetal heart for accurate monitoring. Progression of dilatation and effacement (A) is not necessary prior to applying the external transducer. Completing a sterile speculum exam (C) and preparing a Nitrazine paper test (D) are unrelated to fetal monitoring and are not indicated in this situation.
A nurse on an antepartum unit is caring for four clients. Which of the following clients should the nurse identify as the priority?
- A. A client who has gestational diabetes and a fasting blood glucose level of 120 mg/dL (less than 95 mg/dL).
- B. A client who is at 34 weeks of gestation and reports epigastric pain.
- C. A client who is at 28 weeks of gestation and has an Hgb of 10.4 g/dL (11 to 16 g/dL).
- D. A client who is at 39 weeks of gestation and reports urinary frequency and dysuria.
Correct Answer: B
Rationale: The correct answer is B because epigastric pain in a pregnant client at 34 weeks of gestation could indicate a serious condition such as preeclampsia. Preeclampsia is a potentially life-threatening condition characterized by high blood pressure and organ damage. It requires immediate assessment and intervention to prevent complications for both the mother and the baby. The other clients have less urgent issues that can be managed with ongoing monitoring and interventions. A: Gestational diabetes with a slightly elevated blood glucose level can be managed with adjustments to diet and medication. C: Mildly low hemoglobin levels can be addressed with iron supplementation and monitoring. D: Urinary frequency and dysuria in a client at 39 weeks of gestation are common symptoms of late-stage pregnancy and do not indicate a critical issue.
A nurse is caring for a client who is in labor and reports increasing rectal pressure. They are experiencing contractions 2 to 3 min apart, each lasting 80 to 90 seconds, and a vaginal examination reveals that their cervix is dilated to 9 cm. The nurse should identify that the client is in which of the following phases of labor?
- A. Passive descent
- B. Active
- C. Early
- D. Descent
Correct Answer: B
Rationale: The correct answer is B: Active phase. At 9 cm dilation, the client is in the active phase of the first stage of labor. This phase is characterized by more rapid cervical dilation (6-10 cm) and increased contractions with shorter intervals. The client's symptoms align with this phase as they are experiencing strong contractions close together, along with increased rectal pressure indicating descent of the fetus. Other choices are incorrect as: A (Passive descent) occurs during the second stage of labor; C (Early phase) is typically before 6 cm dilation; D (Descent) is not a recognized phase of labor.