A patient is about to undergo an amniocentesis. tion on her postpartum clients. Which client has a Which procedures should the nurse perform? Select high risk for postpartum hemorrhage? Select all all that apply.
- A. Have the patient give verbal consent for the
- B. Client who delivered vaginally at 40 weeks procedure.
- C. Client who delivered by cesarean delivery because
- D. Assess for bleeding disorders.
Correct Answer: A
Rationale: Having the patient give verbal consent for the procedure is a standard practice and an important step to ensure that the patient understands the risks and benefits of the amniocentesis.
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A nurse is caring for a client who is in labor and has an external fetal monitor. The nurse observes late decelerations on the monitor strip and interprets them as indicating which of the following?
- A. Uteroplacental insufficiency
- B. Maternal bradycardia
- C. Umbilical cord compression
- D. Fetal head compression
Correct Answer: A
Rationale: Late decelerations on the fetal monitor strip indicate uteroplacental insufficiency. These decelerations occur after the peak of a contraction, and the fetus may not receive enough oxygen-rich blood during contractions. Uteroplacental insufficiency can lead to fetal hypoxia and acidosis if not addressed promptly. It is important for the nurse to take appropriate steps to improve fetal oxygenation, such as repositioning the mother, administering oxygen, and adjusting IV fluids. If late decelerations persist, further interventions may be necessary to ensure the well-being of the fetus.
During a nursing assessment the woman with rupture
- A. What is the nurse's priority action?
- B. Use gravity and manipulation to relieve compression of the cord (butt up in the air and face down until ready to delivery)
- C. Help the fetal head descend faster
- D. Facilitate dilation of the cervix with prostaglandin gel
Correct Answer: A
Rationale: In the scenario presented, the nurse's priority action should be to call for emergent medical assistance. A woman with a rupture during a nursing assessment could be experiencing a serious complication known as umbilical cord prolapse. This occurs when the umbilical cord slips through the cervix ahead of the baby, which can lead to compression of the cord and a serious decrease in oxygen supply to the baby. It is a medical emergency that requires immediate intervention by the healthcare team, which may include moving the mother into a knee-chest position or performing a cesarean section. Therefore, the priority action for the nurse is to ensure prompt medical intervention to protect the well-being of both the mother and the baby.
A client at 12 weeks' gestation complains of nausea. What dietary advice should the nurse provide?
- A. Eat three large meals a day.
- B. Avoid drinking fluids between meals.
- C. Increase intake of spicy foods.
- D. Consume high-fat snacks frequently.
Correct Answer: B
Rationale: Avoiding fluids during meals can help reduce nausea by minimizing gastric distension.
How should a nurse assess for proper latch during breastfeeding?
- A. Ensure the baby's nose is covered during feeding
- B. Ensure the baby's lips are sealed around the areola
- C. Check for audible swallowing during feeding
- D. Encourage frequent feeding attempts
Correct Answer: B
Rationale: Ensuring the baby's lips are sealed around the areola promotes effective milk transfer and reduces pain.
The nurse is monitoring a client during the second stage of labor. What finding indicates that birth is imminent?
- A. Client reports the urge to push.
- B. Contractions are irregular.
- C. Fetal heart rate is 140 beats/minute.
- D. Cervix is dilated to 8 cm.
Correct Answer: A
Rationale: The urge to push is a sign that the baby is descending, indicating that delivery is near.