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The labor and delivery unit is short-staffed, and the charge nurse must prioritize assignments. Which client should the registered nurse personally assess first?
- A. A primigravida at 4 cm dilation requesting pain relief.
- B. A multigravida at 8 cm dilation with a history of rapid labors.
- C. A primigravida with stable vital signs post-epidural.
- D. A multigravida at 6 cm dilation with a reassuring fetal monitor.
Correct Answer: B
Rationale: A multigravida at 8 cm dilation with a history of rapid labors is at risk for precipitous delivery, requiring immediate RN assessment to prepare for birth. Other clients are less urgent, as they are earlier in labor or stable.
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A laboring client at -2 station has a spontaneous rupture of the membranes and a cord immediately protrudes from the vagina. The nurse should first:
- A. Place gentle pressure upward on the fetal head.
- B. Place the cord back into the vagina to keep it moist.
- C. Begin oxygen by face mask at 8 to 10 L/min.
- D. Turn the client on her left side.
Correct Answer: A
Rationale: Gentle pressure prevents cord compression.
A primiparous client who delivered vaginally 8 hours ago desires to take a shower. The nurse anticipates remaining nearby the client to assess for which of the following?
- A. Fatigue.
- B. Fainting.
- C. Diuresis.
- D. Hygiene needs.
Correct Answer: B
Rationale: Fainting is a risk during the first shower postpartum due to potential orthostatic hypotension or fatigue, requiring close monitoring.
After the nurse teaches a primiparous client planning to return to work in 6 weeks about storing breast milk, which of the following client statements indicates the need for further teaching?
- A. I can let the milk sit out in a bottle for up to 10 hours.
- B. I'll be sure to label the milk with the date, time, and amount.
- C. I can store the milk for 3 days in the refrigerator.
- D. I can keep the milk in a deep-freeze in clean glass bottles for up to 1 year.
Correct Answer: A
Rationale: Breast milk should not be left out for more than 4-6 hours; 10 hours risks spoilage.
A preterm infant delivered 2 hours ago at 34 weeks' gestation is experiencing rapid respirations, grunting, no breath sounds on one side, and a shift in location of heart sounds. The nurse should prepare to assist with which of the following?
- A. Placement of the neonate on a ventilator.
- B. Administration of bronchodilators through the nurse.
- C. Suctioning of the neonate's nares with wall suction.
- D. Insertion of a chest tube into the neonate.
Correct Answer: D
Rationale: These symptoms suggest a pneumothorax, and inserting a chest tube is the priority to relieve air trapping.
The nurse is evaluating the client who delivered vaginally 2 hours ago and is experiencing postpartum pain rated 8 on scale of 1 to 10. The client is a G 4, P 4, breast-feeding mother who would like medication to decrease the pain in her uterus. Which of the medications listed on the orders sheet would be the most appropriate for this client?
- A. Aspirin 1,000 mg P.O. q 4 to 6 hour p.r.n.
- B. Ibuprofen 800 mg P.O. q 6 to 8 hour p.r.n.
- C. Colace 100 mg P.O. b.i.d.
- D. Vicodin 1 to 2 tabs P.O. q 4 to 6 hour p.r.n.
Correct Answer: B
Rationale: Ibuprofen is safe for breastfeeding mothers and effective for uterine cramping pain, unlike aspirin (risk of bleeding), Colace (stool softener), or Vicodin (opioid, less preferred due to sedation risks).