Nokea
Laboring woman
The most appropriate time for the nurse to encourage a laboring woman to push is during
- A. the interval between contractions.
- B. whenever she feels the need.
- C. second-stage of labor.
- D. first-stage of labor.
Correct Answer: C
Rationale: The second stage of labor, when the cervix is fully dilated, is the appropriate time to push, as contractions are strong and effective for delivery.
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Newborn immediately after birth
The priority nursing care of the newborn immediately after birth includes all except:
- A. Support thermoregulation.
- B. Identify the infant.
- C. Promote normal respirations.
- D. Announcement of the delivery.
Correct Answer: D
Rationale: Announcement of the delivery is not a priority in nursing care of the newborn immediately after birth. While it may be a joyful moment for the parents and family, it does not affect the health and well-being of the newborn. Therefore, it can be done later after the essential newborn care has been completed.
Newborn, signs of diaphoresis, jitteriness, lethargy
A nurse is caring for a newborn and observes signs of diaphoresis, jitteriness, and lethargy. Which of the following actions should the nurse take?
- A. Obtain blood glucose by heel stick.
- B. Initiate phototherapy.
- C. Monitor the newborn's blood pressure.
- D. Place the newborn in a radiant warmer.
Correct Answer: A
Rationale: These symptoms suggest hypoglycemia, and obtaining a blood glucose level via heel stick is the priority to confirm and guide treatment.
Client considered for amniotomy
The nurse understands which condition is a contraindication for an amniotomy.
- A. Right occiput posterior position.
- B. -2 station.
- C. Cephalic presentation.
- D. Dilation less than 3 cm.
Correct Answer: D
Rationale: Dilation less than 3 cm is a contraindication for amniotomy due to increased risks of infection and cord compression.
Newborn reflex observation
What reflex is elicited: Fanning of toes when stroking lateral edge of baby's foot?
- A. Babinski's Reflex.
- B. Stepping Reflex.
- C. Moro reflex.
- D. Plantar Grasp reflex.
Correct Answer: A
Rationale: Babinski's Reflex is elicited by fanning of the toes when the lateral edge of the foot is stroked, normal in infants up to 2 years.
Client receiving oxytocin (Pitocin) infusion
The priority nursing care associated with an oxytocin (Pitocin) infusion is:
- A. Measuring urinary output.
- B. Evaluating cervical dilation.
- C. Increasing infusion rate every 30 minutes.
- D. Monitoring uterine response.
Correct Answer: D
Rationale: Monitoring uterine response is critical as oxytocin can cause excessive contractions, risking fetal distress, uterine rupture, or placental abruption.