Nokea
The nurse is assessing a client in the second stage of labor. What is the nurse's priority assessment?
- A. Frequency of contractions.
- B. Cervical dilation.
- C. Fetal descent and position.
- D. Intensity of contractions.
Correct Answer: C
Rationale: The correct answer is C: Fetal descent and position. In the second stage of labor, the priority assessment is to monitor fetal descent and position to ensure the baby is progressing through the birth canal correctly. This assessment helps determine if interventions are needed to prevent complications such as fetal distress or prolonged labor. Assessing the frequency of contractions (A) and cervical dilation (B) are important but not the priority in the second stage. Intensity of contractions (D) is also important but not as crucial as monitoring fetal descent and position.
You may also like to solve these questions
The nurse is assessing a client with hyperemesis gravidarum. What lab finding is most concerning?
- A. Elevated hematocrit.
- B. Decreased potassium.
- C. Increased white blood cell count.
- D. Low fasting blood glucose.
Correct Answer: B
Rationale: The correct answer is B: Decreased potassium. In hyperemesis gravidarum, excessive vomiting can lead to electrolyte imbalances, particularly hypokalemia. Potassium plays a crucial role in nerve and muscle function, so a low potassium level can result in serious complications such as cardiac arrhythmias. Elevated hematocrit (A) may indicate dehydration, but it is not as immediately concerning as potassium imbalance. Increased white blood cell count (C) may suggest infection but is not directly related to hyperemesis gravidarum. Low fasting blood glucose (D) can occur due to inadequate nutrient intake but is not the most concerning finding in this case.
Which of the following should be implemented in is experiencing increased oral mucus should provide management of hypovolemic shock due to postpar- parent education on which of the following? tum hemorrhage? Select all that apply.
- A. Correctly positioning the infant for feedings
- B. IV fluid replacement with 5% dextrose
- C. Initiating cardiopulmonary resuscitation
- D. Administration of oxygen with a nonrebreather
Correct Answer: A
Rationale: The correct answer is A: Correctly positioning the infant for feedings. This is the most appropriate intervention as it addresses the specific issue of increased oral mucus in an infant, which can be a sign of difficulty feeding and potential aspiration. Positioning the infant correctly can help facilitate safe and effective feeding, reducing the risk of complications.
Summary of why other choices are incorrect:
B: IV fluid replacement with 5% dextrose - This choice does not directly address the issue of increased oral mucus and hypovolemic shock due to postpartum hemorrhage.
C: Initiating cardiopulmonary resuscitation - This choice is not indicated for the given scenario and is more appropriate for a life-threatening emergency situation.
D: Administration of oxygen with a nonrebreather - While oxygen may be necessary in certain cases, it does not address the specific issue of increased oral mucus and hypovolemic shock due to postpartum hemorrhage.
Upon delivery of the newborn, the nursing intervention that most promotes parental attachment is:
- A. Placing the infant under the radiant warmer
- B. Allowing the mother to rest immediately after delivery
- C. Placing the newborn on mother's chest and abdomen
- D. Taking the newborn to the nursery for the initial assessment
Correct Answer: C
Rationale: The correct answer is C: Placing the newborn on mother's chest and abdomen. This promotes parental attachment through skin-to-skin contact, facilitating bonding and emotional connection. It also helps regulate the baby's temperature and encourage breastfeeding. Placing the infant under the radiant warmer (A) may disrupt immediate bonding. Allowing the mother to rest (B) is important, but promoting attachment should be prioritized. Taking the newborn to the nursery (D) can delay the crucial bonding process.
What is the priority action for a mother with a fever during labor?
- A. Administer antipyretics
- B. Provide IV antibiotics
- C. Encourage hydration orally
- D. Notify the healthcare provider immediately
Correct Answer: B
Rationale: The correct answer is B: Provide IV antibiotics. Fever during labor could indicate infection, which can be harmful to both the mother and baby. Administering IV antibiotics is the priority action to treat the infection promptly and prevent complications. Administering antipyretics only treats the symptom, not the underlying cause. Encouraging hydration orally may be important but should not take precedence over addressing a potential infection. Notifying the healthcare provider is important, but immediate intervention with antibiotics is crucial in this situation.
A nurse is caring for a client who is in labor and has a diagnosis of group B streptococcus B-hemolytic infection. Which of the following medications should the nurse plan to administer?
- A. Ampicill in
- B. Azithro mycin
- C. Ceftriax one
- D. Acyclov ir
Correct Answer: A
Rationale: The correct answer is A: Ampicillin. Group B Streptococcus (GBS) infection during labor is typically treated with intravenous antibiotics like ampicillin to prevent transmission to the newborn. Ampicillin is the first-line treatment for GBS during labor due to its effectiveness in eradicating the bacteria and reducing the risk of neonatal infection. Azithromycin (B) is not typically used for GBS infection during labor. Ceftriaxone (C) is not the preferred antibiotic for GBS during labor. Acyclovir (D) is used to treat viral infections, not bacterial infections like GBS.