Nokea
An unlicensed assistive personnel (UAP) reports to the charge nurse that a client who delivered a 7-pound (3,175 gram) infant 12 hours ago is reporting a severe headache. The client's blood pressure is 110/70 mm Hg, respiratory rate is 18 breaths/minute, heart rate is 74 beats/minute, and temperature is 98.6° F (37° C). The client's fundus is firm and one fingerbreadth above the umbilicus. Which action should the charge nurse implement first?
- A. Assign a practical nurse (PN) to reassess the client's vital signs.
- B. Obtain a STAT hemoglobin and hematocrit
- C. Notify the healthcare provider of the assessment findings
- D. Determine if the client received anesthesia during delivery
Correct Answer: C
Rationale: A severe headache post-delivery may indicate a post-dural puncture headache, especially if anesthesia was used, requiring immediate notification of the healthcare provider.
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What is the most important assessment for the nurse to conduct following the administration of epidural anesthesia to a client who is at 40-weeks gestation?
- A. Level of pain sensation.
- B. Variability of fetal heart rate
- C. Maternal blood pressure
- D. Station of presenting part
Correct Answer: C
Rationale: Epidural anesthesia can cause a sudden drop in maternal blood pressure, which may affect placental perfusion, making blood pressure monitoring the priority.
A client who delivered vaginally 2 days ago states that she wants to resume using her diaphragm for birth control. What information should the nurse share with her?
- A. The diaphragm must be refitted after childbirth
- B. The most effective form of contraception is a diaphragm
- C. The diaphragm should be inserted 2 to 4 hours before intercourse.
- D. Vaseline lubricant can be used when inserting the diaphragm
Correct Answer: A
Rationale: Childbirth can alter vaginal and cervical anatomy, requiring the diaphragm to be refitted for effective contraception.
After two miscarriages, a client is instructed to increase her daily intake of foods that includes folic acid. The client does not like green leafy vegetables and states she is allergic to soy. Which food should the nurse suggest that the client eat to obtain folic acid?
- A. Strawberries
- B. Collard greens.
- C. Whole milk
- D. Yogurt
Correct Answer: A
Rationale: Strawberries provide a moderate amount of folic acid and are suitable given the client's dislike for green leafy vegetables and soy allergy.
During the newborn admission assessment, the nurse palpates the newborn's scrotum and does not feel the testicles. Which assessment technique should the nurse perform next to verify the absence of testes?
- A. Use a fingertip to palpate the inguinal canal for a weakening or indentation
- B. Measure the size of the scrotal sac for length and width.
- C. Perform transillumination of the scrotal sac to visualize shadows of the testes
- D. Observe the urethral opening on the surface of the penis when the newborn voids
Correct Answer: A
Rationale: Palpating the inguinal canal is the next step to check for undescended testes, which may be located in the inguinal area.
Which type of anesthesia, used with a client in labor, produces a loss of sensation only to the vagina and perineum?
- A. Epidural block
- B. Saddle block
- C. Paracervical block.
- D. Pudendal block
Correct Answer: D
Rationale: A pudendal block targets the pudendal nerve, numbing only the vagina and perineum, making it ideal for the second stage of labor.