The nurse is assessing a pregnant client who reports dizziness and lightheadedness when lying on her back. What is the priority intervention?
- A. Administer oxygen via face mask.
- B. Place the client in a left lateral position.
- C. Encourage deep breathing exercises.
- D. Increase IV fluid rate.
Correct Answer: B
Rationale: Supine hypotension syndrome is relieved by positioning the client on her left side to improve blood flow.
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The nurse is monitoring a client with suspected placental abruption. What is a key assessment finding?
- A. Painless vaginal bleeding.
- B. Hard, rigid abdomen with severe pain.
- C. Clear amniotic fluid.
- D. Regular uterine contractions.
Correct Answer: B
Rationale: A hard, rigid abdomen and severe pain are classic signs of placental abruption, requiring urgent intervention.
How should a nurse assess for proper latch during breastfeeding?
- A. Ensure the baby's nose is covered during feeding
- B. Ensure the baby's lips are sealed around the areola
- C. Check for audible swallowing during feeding
- D. Encourage frequent feeding attempts
Correct Answer: B
Rationale: Ensuring the baby's lips are sealed around the areola promotes effective milk transfer and reduces pain.
The nurse is assessing a client with suspected preeclampsia. What symptom supports this diagnosis?
- A. Hyperglycemia.
- B. Proteinuria.
- C. Increased fetal movement.
- D. Hypotension.
Correct Answer: B
Rationale: Proteinuria is a hallmark symptom of preeclampsia, along with hypertension and other systemic findings.
Multiparous patient admitted to labor unit with regular contractions 2 minutes apart and last 60 seconds. She reports labor began 6 hours ago and she had bloody show earlier this morning.The patient asks what stage of labor she is in
- A. Transition phase
- B. Active phase
- C. Latent phase
- D. Second stage
Correct Answer: B
Rationale: Based on the information provided, the patient is experiencing regular contractions 2 minutes apart lasting 60 seconds, and she had a bloody show earlier in the morning. These signs in a multiparous patient with 6 hours of labor indicate she is most likely in the transition phase of labor. The transition phase is characterized by intense contractions that are closer together, typically 2-3 minutes apart, and lasting longer, usually around 60-90 seconds. This stage signifies the progression towards the final stages of labor, leading up to the pushing stage and delivery. Therefore, the correct answer is B, Transition phase.
How should a nurse handle a newborn with meconium-stained amniotic fluid?
- A. Suction the airway immediately after birth
- B. Monitor for signs of aspiration
- C. Encourage immediate skin-to-skin contact
- D. Administer antibiotics to the newborn immediately
Correct Answer: A
Rationale: Suctioning the airway immediately reduces the risk of aspiration and respiratory complications.