Nokea
The nurse in the newborn nursery has just received shift report about a group of newborns and is to receive another admission in 30 minutes. In order to provide the safest care and plan for the new admission, the nurse should do which of the following in order of first to last?
- A. Move quickly from room to room and assess all clients.
- B. Check the room to which the new client will be admitted to be sure all supplies and equipment are available.
- C. Log on to the clinical information system and determine if there are new orders.
- D. Review notes from shift report and prioritize all clients; make rounds on the most critical first.
Correct Answer: D,C,A,B
Rationale: First, review and prioritize clients (D). Then, check for new orders (C), assess all clients (A), and finally prepare the room for the new admission (B).
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One-half hour after vaginal delivery of a term neonate, the nurse palpates the fundus of a primigravid client, noting several large clots and a small trickle of bright red vaginal bleeding. The client's blood pressure is 136/92 mm Hg. Which of the following would the nurse do first?
- A. Continue to monitor the client's fundus every 15 minutes.
- B. Ask the physician for an order for methylergonovine (Methergine).
- C. Immediately notify the physician of the client's symptoms.
- D. Change the client's perineal pads every 15 minutes.
Correct Answer: C
Rationale: Large clots and bright red bleeding post-delivery suggest possible uterine atony or retained placental fragments, requiring immediate physician notification for intervention. Monitoring, requesting medication, or changing pads are secondary actions.
The nurse has obtained a urine specimen from a G 6, P 5 client admitted to the labor unit. The woman asks to go to the bathroom and reports that she feels she has to move her bowels. Which actions would be appropriate? Select all that apply.
- A. Assisting her to the bathroom.
- B. Applying an external fetal monitor to obtain fetal heart rate.
- C. Assessing her stage of labor.
- D. Asking if she had back labor pains like this with any of her other deliveries.
- E. Allowing her support person to take her to the bathroom to maintain privacy.
- F. Checking the degree of fetal descent.
Correct Answer: C,F
Rationale: The urge to move bowels often indicates advanced labor or fetal descent in a multiparous client. Assessing the stage of labor and fetal descent (via vaginal exam) confirms progression and prevents unattended delivery. Assisting to the bathroom or relying on a support person risks delivery, and fetal monitoring or past labor history are secondary.
Which of the following should the nurse include in the discharge teaching for a primiparous client about preventing postpartum infections?
- A. Change perineal pads every 8 hours.
- B. Take warm sitz baths twice daily.
- C. Wash hands before and after perineal care.
- D. Use a hairdryer to dry the perineal area.
Correct Answer: C
Rationale: Hand washing before and after perineal care reduces the risk of introducing pathogens, preventing infections.
When assessing a 16-year-old primigravid client at 37 weeks' gestation diagnosed with severe preeclampsia, which of the following indicates the client needs continued management for the preeclampsia?
- A. Blood pressure of 138/94 mm Hg.
- B. Severe blurring of vision.
- C. Less than 2 g of protein in a 24-hour sample.
- D. Weight gain of 0.5 lb in 1 week.
Correct Answer: B
Rationale: Severe blurring of vision indicates worsening preeclampsia.
When teaching a primiparous client about the growth and development of the neonate, which of the following should the nurse include as the usual age at which most babies are able to drink from a cup independently?
- A. 5 to 7 months.
- B. 8 to 10 months.
- C. 12 to 14 months.
- D. 15 to 16 months.
Correct Answer: C
Rationale: Most babies can drink from a cup independently by 12-14 months as motor skills develop.