Nokea
The nurse is caring for a client at 39 weeks' gestation in active labor. The fetal monitor shows late decelerations. What is the priority nursing action?
- A. Reposition the client to her left side.
- B. Increase the oxytocin infusion rate.
- C. Encourage the client to push harder.
- D. Notify the healthcare provider immediately.
Correct Answer: A
Rationale: Repositioning improves uteroplacental blood flow and oxygen delivery to the fetus, addressing late decelerations.
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What is the primary nursing action for a newborn experiencing signs of hypoglycemia?
- A. Administer glucose water via a bottle
- B. Feed the newborn breastmilk or formula
- C. Monitor glucose levels and reassess in 30 minutes
- D. Start an IV glucose drip
Correct Answer: B
Rationale: Feeding with breastmilk or formula is the most effective intervention for neonatal hypoglycemia.
The nurse is educating a client about signs of labor. Which statement indicates understanding?
- A. False labor contractions cause cervical changes.
- B. True labor contractions decrease with activity.
- C. True labor contractions become stronger and more regular.
- D. False labor contractions are felt in the back.
Correct Answer: C
Rationale: True labor is characterized by regular, strong contractions that lead to cervical changes.
The nurse is caring for a G5 in labor. The membrane
- A. Which nursing action is most important to undertake at this time?
- B. Complete sterile vaginal exam
- C. Assess odor of amniotic fluid
- D. Perform Leopold's maneuver
Correct Answer: A
Rationale: The most important nursing action to undertake at this time is obtaining a fetal heart rate (FHR) assessment. Monitoring the FHR is crucial during labor to assess the well-being of the baby and detect any signs of fetal distress. This information helps guide the healthcare team in determining the appropriate course of action to ensure the safety of both the mother and baby. It takes precedence over other tasks such as completing a sterile vaginal exam, assessing the odor of amniotic fluid, performing Leopold's maneuver, or obtaining pain medication orders. Monitoring the FHR should be the immediate priority in this situation.
Why is it important to consider special considerations, such as age, cultural background, or specific health conditions, during a health history for a well-person exam?
- A. to tailor the examination and screening tests to the individual’s health needs
- B. to assess the risk of occupational and environmental exposures
- C. to determine the individual's immunization history
- D. to identify potential safety considerations, such as intimate partner violence or mental abuse
Correct Answer: A
Rationale:
A patient has just had a Mirena IUD inserted. What is the most important information for the nurse to include in the post-procedure instructions?
- A. You may experience severe cramping and should rest for several days.
- B. You should check the strings of the IUD regularly to ensure it is in place.
- C. You should avoid sexual activity for the first month after the insertion.
- D. The IUD will make your periods longer and heavier for the first 6 months.
Correct Answer: B
Rationale: The patient should be instructed to check the strings of the IUD regularly to ensure it remains in place. Choice A is not accurate because while cramping is common, rest is not necessarily required for several days. Choice C is not required; there is no need to avoid sexual activity unless there is an infection or other complication. Choice D is incorrect as Mirena typically reduces bleeding or makes periods lighter.