Nokea
Immediately after the forceps assists in the birth of an infant, what should the nurse do with the baby?
- A. Assess infant for signs of trauma
- B. Administer a vitamin K injection
- C. Provide immediate breastfeeding
- D. Monitor for signs of hypoglycemia
Correct Answer: A
Rationale: Rationale: Immediately after forceps-assisted birth, assessing the infant for signs of trauma is crucial for detecting any injuries or complications. This ensures prompt intervention if needed. Administering a vitamin K injection, providing immediate breastfeeding, and monitoring for hypoglycemia are important but secondary tasks that can be done after ensuring the infant's safety.
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The nurse is reviewing a prenatal chart and notes a client with placenta previa. What is the priority nursing consideration?
- A. Encourage vaginal delivery.
- B. Avoid vaginal examinations.
- C. Encourage bed rest at home.
- D. Prepare for immediate induction of labor.
Correct Answer: B
Rationale: The correct answer is B: Avoid vaginal examinations. Placenta previa is a condition where the placenta partially or completely covers the cervix, increasing the risk of bleeding. Vaginal examinations can trigger bleeding by disrupting the placenta. The priority is to minimize the risk of bleeding and prevent complications. Encouraging vaginal delivery (A) is contraindicated due to the risk of hemorrhage. Bed rest at home (C) may be recommended but is not the priority. Immediate induction of labor (D) can be dangerous and is not indicated unless there is an emergency situation.
The nurse is monitoring a client in active labor with ruptured membranes. What finding requires immediate action?
- A. Contractions every 3–5 minutes.
- B. Temperature of 100.4°F.
- C. Fetal heart rate of 100 beats/minute.
- D. Clear amniotic fluid.
Correct Answer: C
Rationale: The correct answer is C: Fetal heart rate of 100 beats/minute. A fetal heart rate of 100 beats/minute is bradycardia, indicating fetal distress and requiring immediate action to prevent adverse outcomes. Contractions every 3-5 minutes are normal in active labor. A temperature of 100.4°F indicates a low-grade fever but is not an immediate concern unless it continues to rise. Clear amniotic fluid is a normal finding after membrane rupture and does not require immediate action. Therefore, monitoring and addressing the fetal heart rate abnormalities are crucial in this situation.
A client at 10 weeks' gestation reports frequent nausea. What dietary advice should the nurse provide?
- A. Consume small, frequent meals throughout the day.
- B. Avoid eating before going to bed.
- C. Drink large amounts of fluids with meals.
- D. Eat only three large meals daily.
Correct Answer: A
Rationale: The correct answer is A. Consuming small, frequent meals helps manage nausea by preventing an empty stomach, which can worsen symptoms. Eating smaller meals throughout the day can help stabilize blood sugar levels and provide a constant source of nutrients. This approach is recommended for managing nausea during early pregnancy.
Choice B is incorrect because avoiding eating before bed does not address the underlying issue of nausea during the day.
Choice C is incorrect because drinking large amounts of fluids with meals may worsen nausea by causing bloating and discomfort.
Choice D is incorrect because eating only three large meals daily can lead to periods of fasting in between meals, which may exacerbate nausea.
The nurse is caring for a client in labor and is monitoring the fetal heart rate patterns. The nurse notes the presence of episodic accelerations on the electronic fetal monitor tracing. Which action is most appropriate?
- A. Notify the health care provider of the findings.
- B. Reposition the mother and check the monitor for changes in the fetal tracing.
- C. Take the mother's vital signs and tell the mother that bed rest is required to conserve oxygen.
- D. Document the findings and tell the mother that the pattern on the monitor indicates fetal well-being.
Correct Answer: D
Rationale: The correct answer is D: Document the findings and tell the mother that the pattern on the monitor indicates fetal well-being. This is the most appropriate action because episodic accelerations in fetal heart rate patterns are a reassuring sign of fetal well-being. By documenting the findings and informing the mother of this, the nurse can provide reassurance and promote a positive birthing experience.
Choice A is incorrect because notifying the health care provider is not necessary for this normal finding. Choice B is incorrect because repositioning the mother and checking the monitor for changes is not needed when episodic accelerations are present. Choice C is incorrect because taking the mother's vital signs and prescribing bed rest is unnecessary and not indicated based on the fetal heart rate pattern.
What is the priority nursing care associated with oxytocin infusion?
- A. Monitoring uterine response (don't want it to ruptur
- C. Measuring urinary output
- D. Check cervical dilation
Correct Answer: A
Rationale: The correct answer is A because monitoring uterine response is crucial when administering oxytocin infusion to prevent uterine hyperstimulation and rupture. This involves assessing contraction frequency, duration, and strength. Measuring urinary output (choice C) is important for overall fluid balance but not directly related to oxytocin infusion. Checking cervical dilation (choice D) is not a priority when administering oxytocin. Choice B is incomplete.