Nokea
The charge nurse is preparing for the day shift on the Labor and Delivery unit. Which of the following would be included in the responsibilities for this position? Select all that apply.
- A. Review the current status of each labor client with the primary nurse.
- B. Admit the new labor client sent from the triage area.
- C. Complete the work of the nurse who had to leave 30 minutes early.
- D. Follow up with the primary nurse after a delivery.
- E. Complete report of unit with the oncoming charge nurse.
Correct Answer: A,D,E
Rationale: Charge nurse responsibilities include reviewing client status, following up post-delivery, and handing off to the next charge nurse to ensure unit oversight. Admitting clients and completing another nurse's work are typically primary nurse duties.
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A primiparous client asks when to transition her bottle-fed neonate to a sippy cup. The nurse should recommend introducing a sippy cup around:
- A. 3 months.
- B. 6 months.
- C. 9 months.
- D. 12 months.
Correct Answer: D
Rationale: Introducing a sippy cup around 12 months aligns with developmental readiness for independent drinking.
After the nurse instructs a 20-year-old nulligravid client on how to perform a breast self-examination, which of the following client statements indicates that the teaching has been successful?
- A. I should perform breast self-examination on the day my menstrual flow begins.
- B. It's important that I perform breast self-examination on the same day each month.
- C. If I notice that one of my breasts is much smaller than the other, I shouldn't worry.
- D. If there is discharge from my nipples, I should call my health care provider.
Correct Answer: D
Rationale: Breast self-examination should be performed about a week after the menstrual period begins, when breasts are least tender. Noticing nipple discharge is a concerning symptom that warrants contacting a healthcare provider, indicating successful teaching.
The physician orders intermittent fetal heart rate monitoring for a 20-year-old obese primigravid client at 40 weeks' gestation who is admitted to the birthing center in the first stage of labor. The nurse should monitor the client's fetal heart rate pattern at which of the following intervals?
- A. Every 15 minutes during the latent phase.
- B. Every 30 minutes during the active phase.
- C. Every 60 minutes during the initial phase.
- D. Every 2 hours during the transition phase.
Correct Answer: B
Rationale: For a low-risk primigravid client in the active phase of the first stage of labor, intermittent fetal heart rate monitoring is typically performed every 30 minutes to ensure fetal well-being, as per standard obstetric guidelines. More frequent monitoring (every 15 minutes) is reserved for the second stage or high-risk cases, while less frequent intervals (every 60 minutes or 2 hours) are insufficient for active labor.
After instruction of a primigravid client at 8 weeks' gestation about measures to overcome early morning nausea and vomiting, which of the following client statements indicates the need for additional teaching?
- A. "I'll eat dry crackers or toast before arising in the morning."
- B. "I'll drink adequate fluids separate from my meals or snacks."
- C. "I'll eat two large meals daily with frequent protein snacks."
- D. "I'll snack on a small amount of carbohydrates throughout the day."
Correct Answer: C
Rationale: Two large meals may worsen nausea; smaller, more frequent meals are recommended.
A client with pregnancy-induced hypertension is to receive magnesium sulfate to run at 3 grams per hour with normal saline to maintain the total I.V. rate at 125 mL/hour. The nurse giving end of shift report stated the client's blood pressures have been elevated during the night. The oncoming nurse checked the client and found magnesium sulfate running at 2 grams per hour. Identify the nursing actions to be taken from first to last.
- A. Correct the I.V. rates to magnesium sulfate running at 3 grams/hour and normal saline to complete total rate at 125 mL/hour.
- B. Initiate an incident report.
- C. Assess the client's current status.
- D. Notify the physician of the incident.
Correct Answer: C,A,D,B
Rationale: Assess the client first, correct the error, notify the physician, and then document the incident.