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Following the vaginal delivery of a 10-pound infant, the nurse assesses a new mothers vaginal bleeding and finds that she has saturated two pads in 30 minutes and has a boggy uterus. What action should the nurse implement first?
- A. Have the client empty her bladder
- B. Inspect the perineum for lacerations
- C. Increase oxytocin IV infusion
- D. Perform fundal massage until firm
Correct Answer: D
Rationale: Fundal massage (D) helps control bleeding by stimulating uterine contractions.
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A hospital has achieved Magnet status. Which indicators would be consistent with this type of certification?
- A. There is stratification of communication in a directed manner between nursing staff and administration.
- B. There is increased job satisfaction of nurses, with a lower staff turnover rate.
- C. Physicians are certified in their respective specialty areas.
- D. All nurses have baccalaureate degrees and certification in their clinical specialty area.
Correct Answer: B
Rationale: Magnet status hospitals demonstrate higher nurse job satisfaction and lower turnover rates, along with improved quality of care.
A client at 39-weeks gestation is admitted to the labor and delivery unit in active labor. The client's cervix is dilated 5 cm, 90% effaced, and the fetus is at 0 station. The client's membranes rupture spontaneously, and the fluid is greenish-brown. What action should the nurse take first?
- A. Assess the fetal heart rate pattern.
- B. Perform a vaginal examination.
- C. Prepare for an emergency cesarean section.
- D. Administer oxygen via face mask.
Correct Answer: A
Rationale: Greenish-brown amniotic fluid indicates meconium-stained fluid, and assessing the fetal heart rate pattern is critical to determine fetal well-being.
When performing daily head to toe assessment of a 1-day old newborn the nurse observes yellow tint to the skin on the forehead, sternum, and abdomen. What action should the nurse take?
- A. Measure bilirubin levels using transcutaneous bilirubinometer
- B. Review maternal medical records for blood type and Rh factor
- C. Prepare the newborn for phototherapy
- D. Evaluate cord results
Correct Answer: A
Rationale: Measuring bilirubin levels (A) is the first step to determine if phototherapy is necessary for jaundice.
When planning care for a laboring client, the nurse identifies the need to withhold solids food while the client is in labored. What is the most important reasons for this nursing intervention?
- A. Nausea occurs from analgesics used during labor
- B. Autonomic nervous system stimulation during labor decrease peristalsis
- C. An increased risk of aspiration can occur if general anesthesia is needed
- D. Gastric emptying time decreases during labor.
Correct Answer: C
Rationale: Aspiration risk (C) is a primary reason for withholding solid foods during labor.
A mother who is breastfeeding her baby receives instructions from the nurse. Which instruction is most effective to prevent nipple soreness?
- A. Wear a cotton bra
- B. Increase nursing time gradually
- C. Correctly place the infant on the breast
- D. Manually express a small amount of milk before nursing
Correct Answer: C
Rationale: The most common cause of nipple soreness is incorrect positioning (C) of the infant on the breast, e.g., grasping too little of the areola or grasping on the nipple.