Nokea
The nurse in a postpartum couplet room is making rounds prior to ending the shift. Which of the following indicate that the safety needs of the clients have been met?
- A. Infant lying on abdomen.
- B. Security tags in place.
- C. Identification system on mother and infant.
- D. Bulb syringe within sight.
- E. Someone in room able to care for infant.
- F. Infant in the mother's bed, side rails up.
- G. Infant in the mother's arms, both asleep.
Correct Answer: B,C,D,E
Rationale: Safety needs are met with security tags, identification systems, a bulb syringe for suctioning, and someone present to care for the infant.
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The physician orders an amnioinfusion for a primigravid client at term who is diagnosed with oligohydramnios. Which of the following should the nurse include in the client's teaching plan about the purpose of this procedure?
- A. To decrease the frequency and severity of variable decelerations.
- B. To minimize the possibility of fetal metabolic alkalosis.
- C. To increase the fetal heart rate accelerations during a contraction.
- D. To raise the amniotic fluid index to more than 15 cm.
Correct Answer: A
Rationale: Amnioinfusion replaces amniotic fluid in oligohydramnios, reducing cord compression and the frequency/severity of variable decelerations. It does not affect metabolic alkalosis, heart rate accelerations, or guarantee a specific fluid index.
When caring for a neonate diagnosed with gastroschisis, which of the following actions should the nurse record to do first?
- A. Weigh the neonate.
- B. Insert an orogastric tube.
- C. Prepare for immediate blood transfusion.
- D. Cover the abdomen with a moistened sterile gauze.
Correct Answer: D
Rationale: Covering the abdomen with moistened sterile gauze prevents infection and dehydration of the exposed intestines, which is the first priority.
A nurse is discussing preterm labor in a prenatal class. After class, a client and her partner ask the nurse to identify again the nursing strategies to prevent preterm labor. The clients need further instruction when they state which of the following?
- A. "I need to stay hydrated all the time."
- B. "I need to avoid any infections."
- C. "I should include frequent rest breaks if we travel."
- D. "Changing to filter cigarettes is helpful."
Correct Answer: D
Rationale: Smoking, even with filter cigarettes, is harmful and should be avoided.
I.V. oxytocin.png
- A. Continue to observe the fetal monitor.
- B. Anticipate rupture of the membranes.
- C. Prepare for fetal oximetry.
- D. Discontinue the Pitocin infusion.
Correct Answer: D
Rationale: Oxytocin (Pitocin) stimulates uterine contractions. If it causes excessive uterine activity (e.g., more than 5 contractions in 10 minutes or contractions lasting longer than 90 seconds), it can reduce placental perfusion
A primigravid client at 41 weeks' gestation is admitted to the hospital's labor and delivery unit in active labor. After 25 hours of labor with membranes ruptured for 24 hours, the client delivers a healthy neonate vaginally with a midline episiotomy. Which of the following nursing diagnoses should the nurse identify as the priority for the client?
- A. Activity intolerance related to difficult labor process.
- B. Sleep deprivation related to prolonged labor.
- C. Situational low self-esteem related to lengthy labor process.
- D. Risk for infection related to birth trauma and prolonged ruptured membranes.
Correct Answer: D
Rationale: Prolonged rupture of membranes (>24 hours) and episiotomy increase infection risk, making this the priority post-delivery. Activity intolerance, sleep deprivation, and self-esteem are less urgent.