Nokea
A primigravid client at 30 weeks' gestation has been admitted to the hospital with premature rupture of the membranes without contractions. Her cervix is 2 cm dilated and 50% effaced. The nurse should next assess the client's:
- A. Red blood cell count.
- B. Degree of discomfort.
- C. Urinary output.
- D. Temperature.
Correct Answer: D
Rationale: Temperature should be assessed to monitor for infection.
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A 24-year-old primipara who has delivered a healthy neonate in the hospital's birthing center plans to bottle-feed her neonate. When developing the nutritional teaching plan for the mother, the nurse should determine that the number of calories required by the neonate each day per pound of body weight is which of the following?
- A. 30 to 35.
- B. 40 to 45.
- C. 50 to 55.
- D. 60 to 65.
Correct Answer: C
Rationale: Neonates require approximately 50-55 calories per pound of body weight daily for growth and development.
A client is considering the cervical cap. Which of the following client statements indicates understanding?
- A. I need a prescription for the cervical cap.
- B. The cervical cap can be left in place for up to 72 hours.
- C. The cervical cap does not require spermicide.
- D. The cervical cap is more effective after childbirth.
Correct Answer: A
Rationale: The cervical cap requires a prescription and fitting by a healthcare provider. It can be left in place for up to 48 hours, requires spermicide, and is less effective after childbirth.
The nurse is teaching a multiparous breast-feeding client about managing mastitis. Which instruction is most appropriate?
- A. Stop breast-feeding until symptoms resolve.
- B. Apply warm compresses before feeding.
- C. Take antibiotics only if fever persists.
- D. Massage the breast vigorously during feeding.
Correct Answer: B
Rationale: Warm compresses before feeding promote milk flow and relieve duct blockage, aiding mastitis resolution.
The nurse on a mother-baby unit who is working on the night shift is revising the planning worksheet for the remaining 2 hours of the shift. The nurse has the following tasks and orders to complete prior to the 7 a.m. change of shift. Using the work plan below, how should the nurse organize the following tasks so that everything is completed by 7 a.m.?
- A. Draw blood for the ordered laboratory tests (CBCs) on 3 postpartum clients with report on charts by shift change.
- B. Start IV of D5 1/2 NS at keep vein open (KVO) rate on postpartum client just prior to change of shift.
- C. Complete admission assessment of newborn turned over to nurse at 5 a.m.
- D. Draw newborn bilirubin level at 6 a.m.
Correct Answer: A,C,D,B
Rationale: 5:00 - Complete admission assessment; 5:30 - Draw CBCs; 6:00 - Draw bilirubin; 6:30 - Start IV. This ensures timely completion.
The nurse is assessing fetal presentation in a multiparous client. The illustration below indicates which of the following types of presentation?
- A. Frank breech.
- B. Complete breech.
- C. Footling breech.
- D. Vertex.
Correct Answer: D
Rationale: Without the illustration, the context suggests a typical presentation for a multiparous client, which is most likely vertex (head-down), the most common and favorable for vaginal delivery.