Nokea
A nurse is caring for a client who is in labor and requests nonpharmacological pain management. Which of the following nursing actions promotes client comfort?
- A. Assisting the client into squatting position
- B. Having the client lie in a supine position
- C. Applying fundal pressure during contractions
- D. Encouraging the client to void every 6 hr.
Correct Answer: A
Rationale: Assisting the client into a squatting position can help relieve pain and discomfort during labor. Squatting can open up the pelvis, allowing the baby to descend and progress through the birth canal more effectively. This position can also help with gravity-assisted delivery, decreasing the pressure on the mother's back and helping to reduce labor pains. Encouraging various positions during labor can provide comfort and promote optimal positioning for delivery.
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What is the priority nursing intervention for a newborn with respiratory distress?
- A. Administer oxygen and position the newborn
- B. Suction the airway and provide stimulation
- C. Start IV antibiotics immediately
- D. Monitor heart rate and blood pressure
Correct Answer: A
Rationale: Administering oxygen and positioning the newborn can improve respiratory function.
The nurse is assessing a client in labor with variable decelerations on the fetal monitor. What is the priority intervention?
- A. Increase oxytocin infusion.
- B. Reposition the client.
- C. Administer oxygen at 10 L/min.
- D. Notify the healthcare provider.
Correct Answer: B
Rationale: Repositioning the client can alleviate umbilical cord compression, the most common cause of variable decelerations.
The nurse is performing a prenatal assessment. What finding is considered a probable sign of pregnancy?
- A. Positive pregnancy test.
- B. Fetal movement felt by the mother.
- C. Visualization of the fetus on ultrasound.
- D. Auscultation of fetal heart tones.
Correct Answer: A
Rationale: A positive pregnancy test is a probable sign but not definitive, as it could result from other conditions.
The nurse is caring for a client pregnant with twins. Which statement indicates that the client needs additional information?
- A. Because both of my twins are boys, I know that they are identical.
- B. If my twins came from one fertilized egg that split, they are identical.
- C. If I have one boy and one girl, I will know they came from two eggs.
- D. It is rare for both twins to be within the same amniotic sac.
Correct Answer: A
Rationale: The statement 'Because both of my twins are boys, I know that they are identical' is incorrect because twins can be fraternal and of the same sex. Identical twins result from one fertilized egg splitting, while fraternal twins result from two separate fertilized eggs.
The nurse is educating a client about the benefits of skin-to-skin contact after delivery. What is one of the key benefits?
- A. Prevents postpartum hemorrhage.
- B. Improves maternal milk production.
- C. Reduces the risk of neonatal jaundice.
- D. Stabilizes neonatal temperature and heart rate.
Correct Answer: D
Rationale: Skin-to-skin contact helps stabilize the newborn's temperature and heart rate while promoting bonding.