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The nurse is caring for a client in active labor with late decelerations on the monitor. What is the priority nursing intervention?
- A. Reposition the client to her side.
- B. Administer IV fluids.
- C. Apply oxygen via face mask.
- D. Notify the healthcare provider.
Correct Answer: A
Rationale: Repositioning improves blood flow and oxygen delivery to the fetus during late decelerations.
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After her baby's birth a patient wishes to begin breastfeeding. The nurse assists the client by:
- A. Positioning the infant to grasp the nipple to express milk.
- B. Giving the infant a bottle first to evaluate the baby's ability to suck
- C. Leaving them alone and allowing the infant to nurse as long as desired
- D. Touching the infant's cheek adjacent to the nipple to elicit the rooting reflex
Correct Answer: A
Rationale: Positioning the infant to grasp the nipple to express milk is an essential step in helping the patient begin breastfeeding successfully. As a nurse, it is crucial to ensure that the infant is properly latched onto the breast to facilitate effective feeding and milk transfer. This involves positioning the infant in a way that allows them to effectively grasp the nipple, promoting proper suckling and milk production. By assisting the patient in positioning the infant correctly, the nurse is supporting the establishment of successful breastfeeding and ensuring optimal nutrition for the baby.
A client at 12 weeks' gestation asks about managing constipation during pregnancy. What is the nurse's best advice?
- A. Take a laxative daily.
- B. Increase fiber intake and fluids.
- C. Avoid physical activity.
- D. Limit vegetable consumption.
Correct Answer: B
Rationale: Increasing dietary fiber and fluids helps relieve constipation, which is common during pregnancy.
How should a nurse respond to a mother asking about newborn hearing screening?
- A. Explain that hearing screening is optional
- B. Reassure the mother that this is a routine test
- C. Inform the mother that hearing screening is mandatory
- D. Provide resources for further testing if needed
Correct Answer: B
Rationale: Hearing screening is a routine test to identify hearing issues early and ensure proper interventions.
A mother is learning how to breastfeed her newborn. tions, moderate variability The lactation nurse is assisting her with this process.
- A. Baseline FHR 140, occasional variable decelera- Which technique is correct? tions, moderate variability
- B. Have the mother stroke the infant's mouth with
- C. Baseline FHR 105, no accelerations, recurrent her nipple so the infant will turn toward the variable decelerations, minimal variability mother's breast for feeding.
- D. Baseline FHR 165, no decelerations, marked
Correct Answer: B
Rationale: Having the mother stroke the infant's mouth with her nipple so the infant will turn toward the mother's breast for feeding is the correct technique when assisting a mother in learning how to breastfeed her newborn. This technique helps stimulate the baby's rooting reflex, which is a natural reflex babies have to turn their head and open their mouth when their cheek is stroked.
The nurse is performing an assessment of a postpartum client. Which finding requires immediate action?
- A. Temperature of 100.4°F.
- B. Foul-smelling lochia.
- C. Fundus firm and midline.
- D. Breast tenderness on palpation.
Correct Answer: B
Rationale: Foul-smelling lochia may indicate an infection and requires prompt medical evaluation.