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Client after amniotomy
After an amniotomy, which action by the nurse takes priority?
- A. Change the patient's gown.
- B. Assess the fetal heart rate.
- C. Estimate the amount of amniotic fluid.
- D. Assess the color of the amniotic fluid.
Correct Answer: B
Rationale: Assessing the fetal heart rate is the priority after an amniotomy to ensure the fetus tolerates the procedure and detect any distress.
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Client at 40 weeks gestation, active labor, 6 cm cervical dilation, 100% effacement, blood pressure 82/52 mm Hg
A nurse is caring for a client who is at 40 weeks gestation and is in active labor. The client has 6 cm of cervical dilation and 100% cervical effacement. The nurse obtains the client's blood pressure reading as 82/52 mm Hg. Which of the following nursing interventions should the nurse perform?
- A. Assist the client to turn onto her side.
- B. Prepare for an immediate vaginal delivery.
- C. Prepare for a cesarean birth.
- D. Assist the client to an upright position.
Correct Answer: A
Rationale: Assisting the client to turn onto her side can improve blood flow to the placenta and increase fetal oxygenation, addressing hypotension which is a common cause of decreased uteroplacental perfusion.
Newborn immediately after birth
The priority nursing care of the newborn immediately after birth includes all except:
- A. Support thermoregulation.
- B. Identify the infant.
- C. Promote normal respirations.
- D. Announcement of the delivery.
Correct Answer: D
Rationale: Announcement of the delivery is not a priority in nursing care of the newborn immediately after birth. While it may be a joyful moment for the parents and family, it does not affect the health and well-being of the newborn. Therefore, it can be done later after the essential newborn care has been completed.
Male newborn, genitalia assessment
The nurse is inspecting a male newborn's genitalia. Which action should the nurse avoid when conducting this assessment?
- A. Inspecting if the urethral opening appears circular.
- B. Retracting the foreskin over the glans to assess for secretions.
- C. Palpating if testes are descended into the scrotal sac.
- D. Inspecting the genital area for irritated skin.
Correct Answer: B
Rationale: Retracting the foreskin over the glans should be avoided as it can cause pain, bleeding, and infection in the newborn. The foreskin is usually adhered to the glans and should not be forcibly retracted.
Woman received 50 mcg fentanyl intravenously 1 hour before delivery
A woman received 50 mcg of fentanyl intravenously 1 hour before delivery. What drug should the nurse have readily available?
- A. Nalbuphine (Nubain).
- B. Naloxone (Narcan).
- C. Butorphanol (Stadol).
- D. Promethazine (Phenergan).
Correct Answer: B
Rationale: Naloxone (Narcan) reverses opioid effects like fentanyl, critical for addressing potential respiratory depression in the newborn.
New mother, postpartum period
Choose the sign or symptom that a new mother should be taught to report:
- A. Occasional uterine cramping when the infant nurses.
- B. Descent of the fundus one fingerbreadth each day.
- C. Reappearance of red lochia after it changes to serous.
- D. Oral temperature that is 37.2 C (99 F) in the morning.
Correct Answer: C
Rationale: Reappearance of red lochia after it becomes serous may indicate uterine atony or retained placental fragments, requiring immediate reporting.