Nokea
The nurse is assessing a multigravida client at 12 weeks' gestation who has been admitted to the emergency department with sharp right-sided abdominal pain and vaginal spotting. Which of the following should the nurse obtain about the client's history? Select all that apply.
- A. History of sexually transmitted infections.
- B. Number of sexual partners.
- C. Last menstrual period.
- D. Cesarean section.
- E. IUD use.
- F. Contraceptive use.
Correct Answer: A,B,C,E,F
Rationale: These factors increase the risk of ectopic pregnancy.
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A neonate at 37 weeks' gestation is delivered by cesarean delivery because of placenta previa. Which of the following would the circulating nurse do first as soon as the neonate is delivered?
- A. Stimulate the neonate to cry vigorously.
- B. Aspirate mucus from the mouth with a bulb syringe.
- C. Begin resuscitation procedures with a bag and mask.
- D. Hold the neonate upright for the mother to view.
Correct Answer: B
Rationale: Aspirating mucus from the mouth with a bulb syringe clears the airway, which is the first priority to ensure breathing.
After giving instruction about the cause of the vaginal bleeding to a multigravid client at 36 weeks' gestation diagnosed with placenta previa, the nurse determines that the teaching has been effective when the client says that the bleeding results from which of the following?
- A. Diminished clotting factors.
- B. Exposure of maternal blood sinuses.
- C. Increased platelet levels.
- D. A large-for-gestational-age fetus.
Correct Answer: B
Rationale: Placenta previa involves exposure of maternal blood sinuses.
During a shift change, the nurse is assigned a new postpartum client who delivered 6 hours ago. Which task should the nurse prioritize?
- A. Perform a fundal assessment.
- B. Educate the client on newborn care.
- C. Assist with breastfeeding initiation.
- D. Administer a prescribed stool softener.
Correct Answer: A
Rationale: Fundal assessment is critical within the first 24 hours to detect complications like hemorrhage.
After teaching the parents of a neonate born with a cleft lip and cleft palate about appropriate feeding techniques, the nurse determines that the mother needs further instruction when the mother says which of the following?
- A. I should clean her mouth with soapy water after feeding.'
- B. I should feed her in an upright position.'
- C. I need to remember to burp her often.'
- D. I may need to use a special nipple for feeding.'
Correct Answer: A
Rationale: Cleaning the mouth with soapy water is inappropriate and could irritate the cleft, indicating a need for further instruction.
The nurse is caring for a primigravid client in active labor who has had two fetal blood samplings to check for fetal hypoxia. The nurse determines that the fetus is showing signs of acidosis when the scalp blood pH is below which of the following?
- A. 7.5.
- B. 7.4.
- C. 7.3.
- D. 7.2.
Correct Answer: D
Rationale: A fetal scalp blood pH below 7.2 indicates acidosis, suggesting fetal hypoxia and the need for intervention. Values above 7.25 are typically reassuring, and 7.2–7.25 may warrant close monitoring.