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The nurse is monitoring a laboring client with oxytocin infusion. What finding requires immediate intervention?
- A. Contractions lasting 60 seconds.
- B. Contractions every 2 minutes.
- C. Fetal heart rate of 100 beats/minute.
- D. Client reports back pain.
Correct Answer: C
Rationale: A fetal heart rate of 100 bpm indicates bradycardia, requiring immediate intervention to ensure fetal well-being.
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A client is experiencing uterine atony after delivery. What is the nurse's first action?
- A. Massage the fundus until firm.
- B. Increase IV fluid rate.
- C. Notify the healthcare provider.
- D. Administer prescribed oxytocin.
Correct Answer: A
Rationale: Fundal massage stimulates uterine contraction and is the initial response to uterine atony to prevent hemorrhage.
The nurse knows that contraindication of the induction of labor includes:
- A. Placenta previa
- B. Diabetes mellitus
- C. PROM
- D. Isoimmunization
Correct Answer: A
Rationale: Placenta previa is a contraindication for the induction of labor because the placenta partially or completely covers the cervix. Inducing labor in this situation can lead to complications such as excessive bleeding and compromised blood flow to the baby. Therefore, it is important to avoid inducing labor in cases of placenta previa to ensure the safety of both the mother and the baby.
LGBTQIA+ families are at higher risk for certain issues more than straight, cisgender parents. What is an example of a vulnerability experienced by LGBTQIA+ families?
- A. increased cases of social exclusion
- B. fewer cases of intimate partner violence
- C. fewer incidents of family trauma
- D. increased cases of social acceptance
Correct Answer: A
Rationale: LGBTQIA+ families often face social exclusion and discrimination, increasing their vulnerability to mental and physical health challenges.
The nurse is performing an assessment on a client who is at 38 weeks' gestation and notes that the fetal heart rate is 174 beats/minute. What is the priority nursing action?
- A. Document the finding.
- B. Check the mother's heart rate.
- C. Notify the health care provider (HCP).
- D. Tell the client that the fetal heart rate is normal.
Correct Answer: C
Rationale: A fetal heart rate above 160 bpm at term may indicate fetal distress, requiring immediate notification of the HCP.
The pediatric nurse is being pulled to the nursery for the day. The census is six neonates. Which 3 neonates are the best client care assignment for the pediatric nurse?? Select all that apply:
- A. An 18-hour post term, breast-fed neonate with jaundice
- B. A 2-day old who has not passed a meconium stool
- C. A recent admission with Apgar score of 8 out of 10
- D. A 1-day-old with caput succedaneum
Correct Answer: A
Rationale: - A. An 18-hour post-term, breast-fed neonate with jaundice would be a good assignment for the pediatric nurse because a neonate with jaundice requires close monitoring of bilirubin levels and feeding patterns. Breastfeeding can also affect jaundice levels, so the nurse can provide education and support to ensure successful breastfeeding and manage jaundice effectively.