Nokea
The nurse is caring for a client at 38 weeks' gestation with suspected placental abruption. What is the priority nursing action?
- A. Assess maternal vital signs and fetal heart rate.
- B. Prepare the client for immediate cesarean delivery.
- C. Administer oxygen at 2 L/min via nasal cannula.
- D. Insert an indwelling urinary catheter.
Correct Answer: A
Rationale: Assessing maternal and fetal status is the first step to determine the urgency and appropriate intervention.
You may also like to solve these questions
A nurse is caring for four newborns. Which of the following newborns should the nurse assess first?
- A. Newborn who has nasal flaring
- B. Newborn who has subconjunctival hemorrhage of the left eye
- C. A newborn who has overlapping suture lines
- D. A newborn who has not rust-stained urine
Correct Answer: A
Rationale: Nasal flaring in a newborn can be a sign of respiratory distress, which is a critical condition that requires immediate attention. It indicates that the newborn is having difficulty breathing and may not be getting enough oxygen. This can be due to various reasons such as lung problems, infections, or other respiratory issues. Therefore, the nurse should assess and address the newborn with nasal flaring first to ensure their breathing is stable and adequate.
Which of the following is a unique risk factor for substance misuse in individuals AFAB?
- A. Genetic predisposition
- B. High socioeconomic status
- C. Regular physical exercise
- D. History of trauma
Correct Answer: D
Rationale:
A nurse is caring for a client who has hyperemesis gravidarum. Which of the following laboratory tests should the nurse anticipate?
- A. Urine Ketones
- B. Rapid plasma regain
- C. Prothrombin time
- D. Urine culture
Correct Answer: A
Rationale: Hyperemesis gravidarum is a severe form of nausea and vomiting during pregnancy that can lead to dehydration and electrolyte imbalances. One important laboratory test that the nurse should anticipate for a client with hyperemesis gravidarum is the urine ketones test. Ketones in the urine can indicate that the body is breaking down fat for energy instead of using glucose, which can occur during prolonged fasting or in conditions like hyperemesis gravidarum where there is severe vomiting leading to inadequate intake of nutrients. Monitoring urine ketones levels helps healthcare providers assess the severity of dehydration and metabolic derangement in these patients. It guides the management of fluid and electrolyte replacement to prevent complications like ketosis and metabolic acidosis.
Which of the following serve as maternal risk factors juice to having a baby who may suffer from birth trauma?
- A. Take her supplement after a meal Select all that apply.
- B. Take her supplement with full glass of tea
- C. Term delivery
- D. Scheduled cesarean delivery
Correct Answer: D
Rationale: Scheduled cesarean delivery serves as a maternal risk factor juice to having a baby who may suffer from birth trauma. Cesarean deliveries, especially scheduled ones without a medical indication, can increase the risk of birth trauma for the baby compared to a vaginal delivery. Birth trauma in infants can include injuries like bruises, fractures, and head trauma due to various factors during the delivery process. It is important to weigh the risks and benefits of delivery methods in consultation with healthcare providers to minimize the chances of birth trauma.
What is the primary nursing concern for a mother receiving magnesium sulfate therapy?
- A. Monitor blood pressure every 4 hours
- B. Monitor deep tendon reflexes hourly
- C. Assess respiratory rate and effort
- D. Prepare for delivery if signs of toxicity appear
Correct Answer: B
Rationale: Monitoring reflexes detects early signs of magnesium toxicity.