Nokea
Following a minor motor vehicle collision, a client at 36-weeks gestation is brought to the emergency center. She is lying supine on a backboard, is awake, and denies any complaints. Her blood pressure is 80/50 mm Hg and her heart rate is 130 beats/minute. Which action should the nurse implement first?
- A. Obtain a blood sample for complete blood count.
- B. Infuse 1,000 mL normal saline using a large bore intravenous (IV) catheter.
- C. Palpate the abdomen for contractions.
- D. Tilt the backboard sideways to displace the uterus laterally.
Correct Answer: D
Rationale: Tilting the backboard relieves uterine compression on the inferior vena cava, addressing supine hypotension syndrome, which is critical to improve maternal blood pressure and fetal perfusion.
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A client who is positive for Neisseria gonorrhoeae vaginally delivered a newborn. Which medication should the nurse administer to the newborn?
- A. Erythromycin ointment.
- B. Neomycin ointment.
- C. Tetracaine eye drops.
- D. Latanoprost eye drops.
Correct Answer: A
Rationale: Erythromycin ointment is the standard prophylaxis for ophthalmia neonatorum caused by Neisseria gonorrhoeae, preventing severe eye infections.
History and Physical:
Laboratory Results:
The client is a 24-year-old pregnant woman. She is gravida 2, para 1 (G2P1). Her mother has a history of type 2 diabetes mellitus.
Which is likely causing this client's increased blood glucose at 28 weeks? Select all that is apply.
- A. Fetal health problems
- B. Decreased cortisol
- C. Increased insulin needs
- D. Placental infection
- E. Normal weight gain of pregnancy
- F. Fetus with macrosomia
Correct Answer: C,E,F
Rationale: Increased insulin needs, normal weight gain, and macrosomia contribute to insulin resistance and hyperglycemia in pregnancy, unlike fetal health issues, decreased cortisol, or placental infection.
When is the best time to administer a rubella vaccine to a client?
- A. After the client reaches 20-weeks gestation.
- B. Immediately, at 6-weeks gestation, to protect this fetus.
- C. Early postpartum, within 72 hours after delivery.
- D. After the client stops breastfeeding.
Correct Answer: C
Rationale: Administering the rubella vaccine postpartum within 72 hours ensures maternal immunity for future pregnancies without fetal risk, as it's a live vaccine contraindicated in pregnancy.
Assessment findings of a 4-hour-old newborn include murmur, irregular respiratory rate at 64 breaths/min, heart rate of 150 beats/min with soft murmur, jitteriness, hypotonic, and weak cry. Based on these findings, which action should the nurse implement?
- A. Obtain a heel stick blood glucose level.
- B. Document the findings in the record.
- C. Swaddle the infant in a warm blanket.
- D. Place a pulse oximeter on the heel.
Correct Answer: A
Rationale: Jitteriness, hypotonia, and weak cry suggest hypoglycemia; a heel stick glucose test is critical for confirmation and prompt treatment.
Abnormal FHR patterns can result in which condition?
- A. Acidemia.
- B. Hypoxia.
- C. Hypoglycemia.
- D. Meconium stool.
- E. Maternal hypotension.
Correct Answer: A,B,D,E
Rationale: Abnormal FHR patterns can lead to acidemia, hypoxia, meconium passage, and maternal hypotension effects, but not directly hypoglycemia.