Nokea
Click to specify which of the following actions the nurse should anticipate including in the client's plan of care. Select all that apply.
- A. Monitor blood pressure.
- B. Initiate contact precautions.
- C. Prepare for amniocentesis .
- D. Apply internal fecal monitor.
- E. Decrease lighting in the client's room
- F. Check urinary output.
- G. Encourage bed rest.
Correct Answer: A,C,G
Rationale: Reposition the client (Trendelenburg or knee-chest)
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Which of the following is a potential complication of a vacuum-assisted delivery?
- A. Fetal distress
- B. Maternal hemorrhage
- C. Neonatal cephalohematoma
- D. All of the above
Correct Answer: D
Rationale: Vacuum-assisted delivery can lead to fetal distress, maternal hemorrhage, and neonatal cephalohematoma.
What is the primary ethical principle guiding nursing practice in maternal and newborn healthcare?
- A. Autonomy
- B. Non-maleficence
- C. Beneficence
- D. Justice
Correct Answer: C
Rationale: The correct answer is C: Beneficence. In maternal and newborn healthcare, beneficence is the primary ethical principle guiding nursing practice. This principle emphasizes the nurse's duty to promote the well-being and best interests of both the mother and the newborn. Nurses must act in a way that benefits their patients and ensures their safety and health. Autonomy (A) focuses on respecting the patient's right to make their own decisions, which is important but not the primary principle in this context. Non-maleficence (B) involves avoiding harm, which is essential but not the primary guiding principle here. Justice (D) pertains to fairness in healthcare access and resource allocation, which is also crucial but not the primary ethical principle for maternal and newborn healthcare.
A nurse is caring for a client who is in the second stage of labor and is experiencing a shoulder dystocia. The provider instructs the nurse to perform the McRoberts maneuver. Which of the following actions should the nurse take?
- A. Apply pressure to the client's fundus.
- B. Press firmly on the client’s suprapubic area.
- C. Move the client onto their hands and knees.
- D. Assist the client in pulling their knees toward their abdomen.
Correct Answer: D
Rationale: The correct answer is D: Assist the client in pulling their knees toward their abdomen. In shoulder dystocia, the baby's shoulder is stuck behind the mother's pubic bone. The McRoberts maneuver involves hyperflexing the mother's legs towards her abdomen to enlarge the pelvic outlet, which can help dislodge the shoulder and facilitate delivery. This action can help create more space for the baby to maneuver and be born. Applying pressure to the fundus (A) does not address the mechanical issue of shoulder dystocia. Pressing on the suprapubic area (B) may not provide the necessary space for the baby to be delivered. Moving the client onto their hands and knees (C) may not be as effective as the McRoberts maneuver in this situation.
What is the recommended method of screening for group B streptococcus during pregnancy?
- A. Culture of a vaginal swab
- B. Rapid antigen test of a vaginal swab
- C. PCR test of a vaginal swab
- D. All of the above
Correct Answer: A
Rationale: Culture of a vaginal swab is the recommended method for screening for group B streptococcus during pregnancy.
A nurse is assessing a late preterm newborn. Which of the following manifestations is an indication of hypoglycemia?
- A. Hypertonia
- B. Increased feeding
- C. Hyperthermia
- D. Respiratory distress
Correct Answer: D
Rationale: The correct answer is D: Respiratory distress. Hypoglycemia in a late preterm newborn can lead to respiratory distress due to inadequate energy supply to respiratory muscles. Hypertonia (choice A) is not a typical manifestation of hypoglycemia. Increased feeding (choice B) is a compensatory mechanism to raise blood glucose levels. Hyperthermia (choice C) is not directly related to hypoglycemia. Therefore, the most appropriate choice indicating hypoglycemia in this scenario is respiratory distress.