Nokea
A primiparous client who underwent a cesarean delivery 30 minutes ago is to receive Rho(D) immune globulin (RhoGAM). The nurse should administer the medication within which of the following time frames after delivery?
- A. 8 hours.
- B. 24 hours.
- C. 72 hours.
- D. 96 hours.
Correct Answer: C
Rationale: RhoGAM should be administered within 72 hours postpartum to prevent Rh sensitization.
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After delivery of a viable neonate, a 20-year-old primiparous client comments to her mother and the nurse about the baby. Which of the following comments would the nurse interpret as a possible sign of potential maternal-infant bonding problems?
- A. He's got my funny-looking ears!'
- B. He's got my mother should give him the first feeding.'
- C. He's a lot bigger than I expected him to be.'
- D. I want to buy him a blue outfit to wear when we get home.'
Correct Answer: B
Rationale: Delegating the first feeding to the grandmother suggests reluctance to engage in early bonding activities, which could indicate bonding issues. Other comments reflect normal observations or positive engagement with the neonate.
I.V. oxytocin.png
- A. Continue to observe the fetal monitor.
- B. Anticipate rupture of the membranes.
- C. Prepare for fetal oximetry.
- D. Discontinue the Pitocin infusion.
Correct Answer: D
Rationale: Oxytocin (Pitocin) stimulates uterine contractions. If it causes excessive uterine activity (e.g., more than 5 contractions in 10 minutes or contractions lasting longer than 90 seconds), it can reduce placental perfusion
A preterm infant delivered 2 hours ago at 34 weeks' gestation is experiencing rapid respirations, grunting, no breath sounds on one side, and a shift in location of heart sounds. The nurse should prepare to assist with which of the following?
- A. Placement of the neonate on a ventilator.
- B. Administration of bronchodilators through the nurse.
- C. Suctioning of the neonate's nares with wall suction.
- D. Insertion of a chest tube into the neonate.
Correct Answer: D
Rationale: These symptoms suggest a pneumothorax, and inserting a chest tube is the priority to relieve air trapping.
The physician orders an amniocentesis for a primigravid client at 35 weeks' gestation in early labor to determine fetal lung maturity. Which of the following is an indicator of fetal lung maturity?
- A. A amount of bilirubin present.
- B. Presence of red blood cells.
- C. Barr body determination.
- D. Lecithin-sphingomyelin (L/S ratio).
Correct Answer: D
Rationale: The lecithin-sphingomyelin (L/S) ratio in amniotic fluid is a key indicator of fetal lung maturity, with a ratio of 2:1 or higher indicating mature lungs. Bilirubin, red blood cells, and Barr body determination are not used for this purpose.
A newly delivered client is asking to go to the bathroom 45 minutes after delivery. She had an epidural for labor & delivery, has an IV infusing, and every 15 minutes assessments are in progress. To provide the safest care for this client the nurse should:
- A. Ask her to remain in bed until the 15-minute assessments are complete.
- B. Assess client's ability to stand and bear weight before going to the bathroom.
- C. Encourage the client to sit at the side of the bed before ambulating to the bathroom.
- D. Ask the client to ambulate the first time with a staff member at her side.
Correct Answer: B
Rationale: Post-epidural, assessing the client's ability to stand and bear weight ensures safety due to potential residual numbness or weakness. Remaining in bed delays care, sitting first is insufficient, and ambulating with assistance assumes mobility not yet confirmed.