Nokea
In which of the following maternal locations would the nurse place the ultrasound transducer of the external electronic fetal heart rate monitor if a fetus at 34 weeks' gestation is in the left occipitoanterior(LOA) position?
- A. Near the symphysis pubis.
- B. Two inches above the umbilicus.
- C. Below the umbilicus on the left side.
- D. At the level of the umbilicus.
Correct Answer: C
Rationale: The transducer should be placed below the umbilicus on the left side for LOA position.
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Which of the following would be most important for the nurse to encourage in a primiparous client diagnosed with endometritis who is receiving intravenous antibiotic therapy?
- A. Ambulate to the bathroom frequently.
- B. Discontinue breast-feeding temporarily.
- C. Maintain bed rest in Fowler's position.
- D. Restrict visitors to prevent contamination.
Correct Answer: C
Rationale: Fowler's position promotes drainage of uterine secretions, aiding recovery from endometritis.
A breast-feeding primiparous client asks the nurse how breast milk differs from cow's milk. The nurse responds by saying that breast milk is higher in which of the following?
- A. Fat.
- B. Iron.
- C. Sodium.
- D. Calcium.
Correct Answer: A
Rationale: Breast milk has higher fat content, which is essential for neonatal growth and brain development.
The nurse is receiving over the telephone a laboratory results report of a neonate's blood glucose level. The nurse should:
- A. Write the results in the chart, and receive confirmation from the caller that the nurse understands the results.
- B. Repeat the results to the caller from the laboratory, write the results on scrap paper first, and then transfer the results to the chart.
- C. Indicate to the caller that the nurse cannot receive verbal results from laboratory tests for neonates, and ask the laboratory to bring the written results to the nursery.
- D. Request that the laboratory send the results by email to transfer to the client's electronic record.
Correct Answer: A
Rationale: Writing the results and confirming with the caller ensures accuracy and compliance with documentation protocols.
A multiparous client at 24 hours postpartum demonstrates a positive Homan's sign with discomfort. The nurse should:
- A. Place a cold pack on the client's perineal area.
- B. Place the client in a semi-Fowler's position.
- C. Notify the client's physician immediately.
- D. Ask the client to ambulate around the room.
Correct Answer: C
Rationale: A positive Homan's sign suggests possible deep vein thrombosis, requiring immediate physician notification.
The physician orders docusate sodium (Colace) 100 mg at bedtime for a primiparous client after vaginal delivery of a term neonate after a midline episiotomy. The nurse instructs the client to expect which of the following results from taking the medication?
- A. Relief from episiotomy pain.
- B. Contraction of the uterus.
- C. Softening of the stool.
- D. Aid in sleeping.
Correct Answer: C
Rationale: Docusate sodium is a stool softener, which helps prevent straining during bowel movements, especially important after an episiotomy.