Nokea
The nurse is caring for a client in labor who reports intense pressure and the urge to push. What is the priority nursing action?
- A. Perform a sterile vaginal examination.
- B. Instruct the client to breathe through the urge to push.
- C. Notify the healthcare provider.
- D. Increase the oxytocin infusion rate.
Correct Answer: A
Rationale: A vaginal examination is needed to confirm full cervical dilation and readiness for delivery.
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A nurse is providing teaching to a client about exercise safety during pregnancy. Which of the following statements by the client indicates an understanding of the teaching? (Select all that apply).
- A. "will limit my time in the hot tub to 30 minutes after exercise."
- B. "should consume three 8-ounce glasses of water after I exercise."
- C. "will check my heart rate every 15 minutes during exercise sessions."
- D. "should limit exercise sessions to 30 minutes when the weather is humid."
Correct Answer: C
Rationale: This response indicates an understanding of the importance of monitoring heart rate during exercise to ensure it stays within a safe range for the pregnant woman and the baby.
A nurse is caring for a client who is in labor and has an external fetal monitor. The nurse observes late decelerations on the monitor strip and interprets them as indicating which of the following?
- A. Uteroplacental insufficiency
- B. Maternal bradycardia
- C. Umbilical cord compression
- D. Fetal head compression
Correct Answer: A
Rationale: Late decelerations on the fetal monitor strip indicate uteroplacental insufficiency. These decelerations occur after the peak of a contraction, and the fetus may not receive enough oxygen-rich blood during contractions. Uteroplacental insufficiency can lead to fetal hypoxia and acidosis if not addressed promptly. It is important for the nurse to take appropriate steps to improve fetal oxygenation, such as repositioning the mother, administering oxygen, and adjusting IV fluids. If late decelerations persist, further interventions may be necessary to ensure the well-being of the fetus.
A newborn has a respiratory rate of 80 breaths/min, nasal flaring with sternal retractions, a heart rate of 120 beats/min, temperature of 36C and a persisting oxygen saturation of <87%. The nurse interprets these findings as:
- A. Cardiac distress
- B. Respiratory Alkalosis
- C. Bronchial pneumonia
- D. Respiratory Distress
Correct Answer: D
Rationale: The newborn's presentation with a respiratory rate of 80 breaths/min, nasal flaring with sternal retractions, a heart rate of 120 beats/min, and persisting low oxygen saturation (<87%) are indicative of respiratory distress. These signs suggest that the newborn is having difficulty breathing and may not be getting enough oxygen into their system. Respiratory distress in newborns is a serious condition that requires immediate attention and intervention to support breathing and oxygenation. It is crucial for healthcare providers to recognize and address respiratory distress promptly to prevent further complications.
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.
A nurse is providing teaching to a group of women about risk factors for ovarian cancer. Which of the following should the nurse include? (Select all that apply.)
- A. Nulliparity
- B. History of breastfeeding (???)
- C. Previous use of oral contraceptives
- D. History of breast cancer
Correct Answer: A
Rationale: A. Nulliparity: Women who have never been pregnant (nulliparity) are at an increased risk for ovarian cancer compared to women who have had full-term pregnancies. This is thought to be due to the protective effect of pregnancy and childbirth on the ovaries.