Nokea
After her baby's birth a patient wishes to begin breastfeeding. The nurse assists the client by:
- A. Positioning the infant to grasp the nipple to express milk.
- B. Giving the infant a bottle first to evaluate the baby's ability to suck
- C. Leaving them alone and allowing the infant to nurse as long as desired
- D. Touching the infant's cheek adjacent to the nipple to elicit the rooting reflex
Correct Answer: A
Rationale: Positioning the infant to grasp the nipple to express milk is an essential step in helping the patient begin breastfeeding successfully. As a nurse, it is crucial to ensure that the infant is properly latched onto the breast to facilitate effective feeding and milk transfer. This involves positioning the infant in a way that allows them to effectively grasp the nipple, promoting proper suckling and milk production. By assisting the patient in positioning the infant correctly, the nurse is supporting the establishment of successful breastfeeding and ensuring optimal nutrition for the baby.
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A nurse is caring for a client who is gravida 3, para 2, and is in active labor. The fetal head is at 3+ station after a vaginal examination. Which of the following actions should the nurse take
- A. Apply fundal pressure.
- B. Observe for the presence of a nuchal cord.
- C. Observe for crowning.
- D. Prepare to administer oxytocin.
Correct Answer: C
Rationale: Observing for crowning is the appropriate action for the nurse to take when the fetal head is at 3+ station after a vaginal examination. Crowning refers to the appearance of the baby's head at the vaginal opening during delivery. This indicates that the baby is descending and will be born soon. It is important for the nurse to be prepared for the actual birth once crowning is observed, as it signifies that the second stage of labor is progressing and delivery is imminent. Applying fundal pressure, observing for a nuchal cord, or preparing to administer oxytocin are not appropriate actions at this stage of labor when crowning has been observed.
The nurse is caring for a client with severe preeclampsia. What finding would indicate magnesium sulfate toxicity?
- A. Increased deep tendon reflexes.
- B. Respiratory rate of 10 breaths per minute.
- C. Urine output of 50 mL/hour.
- D. Blood pressure of 160/110 mmHg.
Correct Answer: B
Rationale: Respiratory depression is a key sign of magnesium sulfate toxicity, requiring immediate action.
The nurse is caring for a patient who could be at risk for uterine
- A. What should the nurse be monitoring the fetus closely for? SATA
- B. Loss of ability to determine fetal station
- C. Bradycardia
- D. Late decelerations
Correct Answer: A
Rationale: A. What should the nurse be monitoring the fetus closely for? SATA
A nurse is caring for a client who is receiving oxytocin to augment labor. The nurse notes recurrent variable decelerations...Which of the following actions should the nurse take first?
- A. Prepare the equipment necessary to initiate an amnioinfusion.
- B. Administer oxygen at 10 L/min via nonrebreather face mask.
- C. Discontinue the infusion of oxytocin.
- D. Place the client in a left lateral position.
Correct Answer: C
Rationale: Recurrent variable decelerations during labor can indicate umbilical cord compression, which can result in fetal hypoxia and distress. Discontinuing the oxytocin infusion is the priority in this situation as oxytocin can cause or exacerbate uteroplacental insufficiency leading to fetal distress. By discontinuing the oxytocin, the nurse can help improve fetal oxygenation and alleviate the variable decelerations. After stopping the oxytocin infusion, the nurse should continue to monitor the fetal heart rate pattern and follow the healthcare provider's orders for further management if needed.
The nurse is performing an assessment of a client who is scheduled for a cesarean delivery at 39 weeks of gestation. Which assessment finding indicates the need to contact the health care provider (HCP)?
- A. Hemoglobin of 11 g/dL (110 mmol/L)
- B. Fetal heart rate of 180 beats/minute
- C. Maternal pulse rate of 85 beats/minute
- D. White blood cell count of 12,000 mm3 (12.0 × 109/L)
Correct Answer: B
Rationale: A fetal heart rate of 180 bpm may indicate fetal distress and warrants immediate HCP notification.