Nokea
A nurse on an antepartum unit is reviewing the medical records for four clients. Which of the following clients should the nurse assess first?
- A. A client who has diabetes mellitus and an HbA1c of 5.8%
- B. A client who has preeclampsia and a creatinine level of 1.1 mg/ dL
- C. A client who has hyperemesis gravidarum and a sodium level of 110 mEq/L
- D. A client who has placenta previa and a hematocrit of 36%
Correct Answer: C
Rationale: A client with hyperemesis gravidarum and a sodium level of 110 mEq/L is at risk for severe dehydration and electrolyte imbalance, particularly hyponatremia (low sodium level). Hyponatremia can lead to serious complications such as seizures, coma, and even death if not promptly addressed. Therefore, this client should be assessed first to prevent any potential life-threatening conditions. The nurse should prioritize interventions to address the electrolyte imbalance and dehydration in this client to ensure their safety and well-being.
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A pregnant client tells the clinic nurse she wants to know the sex of her baby as soon as it can be determined. What factor allows this at 12 weeks' gestation?
- A. The appearance of the fetal external genitalia
- B. The beginning of differentiation in the fetal groin
- C. The fetal testes are descended into the scrotal sac
- D. The internal differences in males and females become apparent
Correct Answer: A
Rationale: By 12 weeks, the external genitalia are sufficiently developed for visual determination of the baby's sex.
A nurse is caring for a client who is in the transition phase of labor and reports a pain level of 7 on a scale of 0 to Which of the following actions should the nurse take?
- A. Instruct the client to use effleurage
- B. Apply counter pressure to the client sacral.
- C. Assist the client with patterned-paced breathing.
- D. Teach the client the technique of biofeedback.
Correct Answer: B
Rationale: In the transition phase of labor, the contractions are intense and the client may experience significant discomfort and pain. Applying counter pressure to the client's sacral area can help alleviate this pain by providing some relief and support. Counter pressure involves applying firm pressure with the palms or fists to the lower back or sacral area during contractions. This technique can help to relieve some of the pressure and discomfort experienced during contractions, making it a beneficial action for the nurse to take in this situation.
4 minutes after the birth of the baby there is a sudden gush of blood from the mom's vagina and the about 8 inches of umbilical cord slides out. What action should nurse take first?
- A. Watch for emergence of placenta
- B. Assess for signs of uterine inversion
- C. Perform fundal massage
- D. Prepare for possible episiotomy repair
Correct Answer: A
Rationale: In this situation, the nurse should first watch for the emergence of the placenta. This is because the gush of blood followed by the umbilical cord slipping out indicates a possible placental abruption, where the placenta separates from the uterine wall before the baby is born. It is crucial to closely monitor the situation for signs of an incomplete placental delivery or any further complications. If the placenta does not deliver within a reasonable timeframe or if there are signs of excessive bleeding or other issues, immediate medical intervention may be necessary.
Which order should the nurse implement first?
- A. Give 1L LR IV (VS indicate hypovolemia from dehydration,
- B. LR will reestablish vascular volume and bring BP up)
- C. Weigh the client
- D. Administer Maalox orally
Correct Answer: A
Rationale: The correct order of implementation in this scenario should focus on addressing the immediate physiological needs of the patient. The vital signs indicating hypovolemia from dehydration require prompt action to stabilize the patient's condition. Giving 1L of LR IV will help reestablish vascular volume, improve blood pressure, and address the underlying issue of dehydration. By addressing the hypovolemia first, the nurse can effectively start the process of stabilizing the patient before moving on to other interventions such as weighing the client, administering Maalox orally, or encouraging liquid intake.
A nurse is caring for four newborns. Which of the following newborns should the nurse assess first?
- A. Newborn who has nasal flaring
- B. Newborn who has subconjunctival hemorrhage of the left eye
- C. A newborn who has overlapping suture lines
- D. A newborn who has not rust-stained urine
Correct Answer: A
Rationale: Nasal flaring in a newborn can be a sign of respiratory distress, which is a critical condition that requires immediate attention. It indicates that the newborn is having difficulty breathing and may not be getting enough oxygen. This can be due to various reasons such as lung problems, infections, or other respiratory issues. Therefore, the nurse should assess and address the newborn with nasal flaring first to ensure their breathing is stable and adequate.