Nokea
The nurse is caring for a postpartum client who reports feeling overwhelmed and tearful. What is the nurse's priority intervention?
- A. Administer a sedative as prescribed.
- B. Encourage the client to rest and sleep.
- C. Provide emotional support and reassurance.
- D. Refer the client to a mental health professional.
Correct Answer: C
Rationale: The correct answer is C: Provide emotional support and reassurance. This is the priority intervention because the client is feeling overwhelmed and tearful, indicating a need for immediate emotional support. Administering a sedative (A) may mask the underlying issue and is not addressing the client's emotional needs. Encouraging rest and sleep (B) is important but secondary to addressing the client's emotional state. Referring the client to a mental health professional (D) may be necessary in the long term but is not the immediate priority in this situation. Emotional support and reassurance can help the client feel validated and supported in the moment.
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Immediately after the forceps assists in the birth of an infant, what should the nurse do with the baby?
- A. Assess infant for signs of trauma
- B. Administer a vitamin K injection
- C. Provide immediate breastfeeding
- D. Monitor for signs of hypoglycemia
Correct Answer: A
Rationale: Rationale: Immediately after forceps-assisted birth, assessing the infant for signs of trauma is crucial for detecting any injuries or complications. This ensures prompt intervention if needed. Administering a vitamin K injection, providing immediate breastfeeding, and monitoring for hypoglycemia are important but secondary tasks that can be done after ensuring the infant's safety.
The nurse is counseling a client on the proper con- admitted to the labor and delivery unit complaining sumption of fish and fish products while pregnant. of mild contractions that are 10 minutes apart. How much fish should the nurse instruct the client After performing Leopold's maneuvers, the nurse to eat? determines that a hard round object is in the uterine
- A. 8 to 12 ounces of a variety of fish every week fundus. What should the nurse do if green fluid is
- B. 8 to 12 ounces of a variety of fish every month noted after rupture of the fetal membranes?
- C. 12 to 16 ounces of a variety of fish every week A.Observe the fetal monitor for variable decelerations
- D. 12 to 16 ounces of a variety of fish every month
Correct Answer: C
Rationale: The correct answer is C: 12 to 16 ounces of a variety of fish every week. During pregnancy, fish is a good source of protein and omega-3 fatty acids which are beneficial for fetal development. Consuming 12 to 16 ounces per week is recommended by health authorities for pregnant women to get essential nutrients without excessive mercury intake. Choice A (8 to 12 ounces of fish every week) is not enough for optimal nutrition during pregnancy. Choice B (8 to 12 ounces of fish every month) is too infrequent for consistent nutrient intake. Choice D (12 to 16 ounces of fish every month) is also inadequate as the frequency is not sufficient for optimal fetal development. Therefore, choice C is the best option for ensuring adequate nutrient intake while minimizing risks associated with mercury consumption.
A nurse is caring for a client who is receiving an epidural block with an opioid analgesic. The nurse should monitor for which of the following findings as an adverse effect of the medication?
- A. Hypnosis
- B. Polyuria
- C. Bilateral crackles
- D. Hyperglycemia
Correct Answer: C
Rationale: The correct answer is C: Bilateral crackles. When a client is receiving an opioid analgesic via an epidural block, a potential adverse effect is respiratory depression, leading to the accumulation of fluid in the lungs and the development of bilateral crackles upon auscultation. Hypnosis (choice A) is not typically associated with opioid analgesics. Polyuria (choice B) is not a common side effect of opioids or epidural blocks. Hyperglycemia (choice D) is not a direct adverse effect of opioid analgesics administered through an epidural block. Monitoring for bilateral crackles is crucial to detect and address respiratory depression promptly.
The nurse is reviewing a prenatal chart and notes a client with placenta previa. What is the priority nursing consideration?
- A. Encourage vaginal delivery.
- B. Avoid vaginal examinations.
- C. Encourage bed rest at home.
- D. Prepare for immediate induction of labor.
Correct Answer: B
Rationale: The correct answer is B: Avoid vaginal examinations. Placenta previa is a condition where the placenta partially or completely covers the cervix, increasing the risk of bleeding. Vaginal examinations can trigger bleeding by disrupting the placenta. The priority is to minimize the risk of bleeding and prevent complications. Encouraging vaginal delivery (A) is contraindicated due to the risk of hemorrhage. Bed rest at home (C) may be recommended but is not the priority. Immediate induction of labor (D) can be dangerous and is not indicated unless there is an emergency situation.
A woman asks about the side effects of the contraceptive implant. Which of the following should the nurse include in the discussion?
- A. The implant will cause heavy menstrual bleeding.
- B. The implant may cause irregular bleeding patterns, including light spotting.
- C. The implant can cause weight gain.
- D. The implant may cause hair loss.
Correct Answer: B
Rationale: The correct answer is B because irregular bleeding patterns, including light spotting, are a common side effect of the contraceptive implant due to hormonal changes. This is important for the woman to be aware of to manage her expectations. Choice A is incorrect as the implant typically leads to lighter periods or no periods at all. Choice C is incorrect as weight gain is not a common side effect of the implant. Choice D is also incorrect as hair loss is not typically associated with the contraceptive implant.