The nurse is caring for a client in labor with meconium-stained amniotic fluid. What is the priority action?
- A. Administer oxygen to the mother.
- B. Notify the healthcare provider.
- C. Prepare for potential neonatal resuscitation.
- D. Increase IV fluid rate.
Correct Answer: C
Rationale: Meconium-stained amniotic fluid poses a risk of aspiration; preparation for neonatal resuscitation is critical.
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The nurse is monitoring a postpartum client with a boggy uterus. What is the priority intervention?
- A. Notify the healthcare provider.
- B. Massage the fundus until firm.
- C. Administer prescribed oxytocin.
- D. Check the client’s vital signs.
Correct Answer: B
Rationale: Massaging a boggy uterus stimulates contraction and reduces the risk of postpartum hemorrhage.
The nurse is caring for a client in the postpartum period. What finding indicates a need for immediate intervention?
- A. Fundus firm and midline.
- B. Lochia rubra with large clots.
- C. Perineal pain after delivery.
- D. Slight swelling of the feet.
Correct Answer: B
Rationale: Large clots in lochia rubra may indicate retained placental fragments or postpartum hemorrhage.
A nurse is caring for a newborn who is 6 hr. old and has a bedside glucometer reading of 65 mg/ dL. The newborn's mother has type 2 diabetes mellitus. Which of the following actions should the nurse take?
- A. Obtain a blood sample for a serum glucose level
- B. Feed the newborn immediately
- C. Administer 50 mL of dextrose solution IV
- D. Reassess the blood glucose level prior to the next feeding
Correct Answer: D
Rationale: The correct action for the nurse to take in this situation is to reassess the blood glucose level prior to the next feeding. A single low bedside glucometer reading is not sufficient to make treatment decisions, especially in a newborn who is only 6 hours old and with a mother having type 2 diabetes mellitus. It is important to follow up with another blood glucose measurement before taking further action. This will help ensure that appropriate interventions are taken based on accurate and reliable information.
The nurse is caring for a postpartum client who is
- A. Maternal hyperglycemia 1 day postcesarean birth. What assessment data
- B. FHR, early decelerations would indicate infection? Select all that apply.
- C. FHR, late decelerations
- D. Increased pulse
Correct Answer: A
Rationale: Maternal hyperglycemia 1 day post-cesarean birth can indicate infection. Hyperglycemia can impair immune function and make the body more susceptible to infections.
The nurse is assessing a client diagnosed with placenta previa. Which findings should the nurse expect to note?
- A. Uterine rigidity.
- B. Severe abdominal pain.
- C. Bright red vaginal bleeding.
- D. Soft, relaxed, nontender uterus.
Correct Answer: C
Rationale: Placenta previa presents as painless bright red bleeding and a soft, non-tender uterus.