Nokea
A delivering patient presses the call light and reports that her water just broke the nurse first action should be:
- A. Check the fetal heart tone
- B. Call physician
- C. Change bed linen
- D. Encourage mother to go for a walk
Correct Answer: A
Rationale: The correct first action when a delivering patient's water breaks is to check the fetal heart tone. This is important to assess the well-being of the baby and ensure there are no signs of distress. Once the fetal heart tone is confirmed, the nurse can proceed with notifying the physician, changing bed linen, and encouraging the mother to go for a walk as needed. But the priority should always be to assess the fetal well-being in such a situation.
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Which nursing intervention is most appropriate for a breastfeeding mother experiencing engorgement?
- A. Apply cold compresses to the breasts after feeding
- B. Limit breastfeeding to every 6 hours
- C. Use formula supplements to reduce milk supply
- D. Massage the breasts before feeding
Correct Answer: A
Rationale: Cold compresses reduce swelling and discomfort during engorgement.
The nurse is caring for a G5 in labor. The membrane
- A. Which nursing action is most important to undertake at this time?
- B. Complete sterile vaginal exam
- C. Assess odor of amniotic fluid
- D. Perform Leopold's maneuver
Correct Answer: A
Rationale: The most important nursing action to undertake at this time is obtaining a fetal heart rate (FHR) assessment. Monitoring the FHR is crucial during labor to assess the well-being of the baby and detect any signs of fetal distress. This information helps guide the healthcare team in determining the appropriate course of action to ensure the safety of both the mother and baby. It takes precedence over other tasks such as completing a sterile vaginal exam, assessing the odor of amniotic fluid, performing Leopold's maneuver, or obtaining pain medication orders. Monitoring the FHR should be the immediate priority in this situation.
A nurse is assessing a newborn who was born vaginally with vacuum extractor assistance ... that crosses the suture line. The nurse should identify the swellings as which of the following....?
- A. Nevus flammeus
- B. Caput uccedaneum
- C. Cephalohematoma
- D. Erythema toxicum
Correct Answer: C
Rationale: Cephalohematoma is a collection of blood between the skull and its periosteum that occurs due to rupture of blood vessels during birth trauma. It is typically found on one side of the head and does not cross the suture line. In contrast, caput succedaneum is a diffuse swelling that occurs on the newborn's scalp and can cross the suture lines. Nevus flammeus is a vascular birthmark that appears as a pink or red patch on the skin, unrelated to trauma. Erythema toxicum is a benign rash that appears as red spots or patches with a white or yellow papule in the center, also unrelated to trauma.
A woman admitted to the labor and delivery unit in bruising over the shoulder area and an abrasion on early labor gives the following obstetric history. She the scalp. What are these markings most likely the gave birth to her daughter at 38 weeks and her twin result of?
- A. Suspected drug use during pregnancy
- B. Abuse by a caregiver
- C. Soft tissue injury during delivery
- D. Blue/gray macule (Mongolian spot)
Correct Answer: B
Rationale: The bruising over the shoulder area and the abrasion on the scalp of a woman admitted to the labor and delivery unit during early labor are most likely the result of abuse by a caregiver. These types of injuries can be indicative of physical abuse, especially in vulnerable populations such as pregnant women. It is important for healthcare providers to be alert for signs of abuse and to report any suspicions or evidence to ensure the safety of the mother and the baby. In cases like this, a thorough assessment and appropriate intervention are necessary to protect the well-being of the mother and the unborn child.
The nurse is caring for a client with severe preeclampsia. What is the priority nursing action?
- A. Administer antihypertensive medication.
- B. Assess for signs of impending eclampsia.
- C. Monitor urine protein levels.
- D. Encourage ambulation.
Correct Answer: B
Rationale: Assessing for signs of impending eclampsia, such as severe headache or visual changes, is critical to prevent seizures.