Nokea
The nurse is caring for a client in the second stage of labor. What assessment indicates that birth is imminent?
- A. Cervix is dilated to 8 cm.
- B. Fetal head is crowning.
- C. Contractions every 3–5 minutes.
- D. Client reports back pain.
Correct Answer: B
Rationale: Crowning occurs when the fetal head becomes visible at the vaginal opening, indicating that birth is imminent.
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The nurse is educating a client about postpartum care. What statement indicates the need for further teaching?
- A. I will call my doctor if I have a fever.
- B. It is normal to have heavy bleeding for two weeks.
- C. I will avoid lifting heavy objects.
- D. Breast tenderness is common when my milk comes in.
Correct Answer: B
Rationale: Heavy bleeding for two weeks is not normal and may indicate postpartum complications.
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.
What is the theory that supports HypnoBirthing?
- A. the fear-tension-pain theory
- B. the theory that pain is productive in labor
- C. the idea that self-hypnosis always works if you try hard enough
- D. the theory that when hypnotized during labor, the environment does not matter because the person is not aware of the surroundings
Correct Answer: A
Rationale: HypnoBirthing is based on the fear-tension-pain theory, which links fear to increased tension and pain.
A mother's laboratory results indicate the presence of cocaine and alcohol. The characteristic in her newborn that would indicate to the nurse that the baby has been affected with fetal alcohol syndrome would be:
- A. Cleft lip
- B. Polydactyly
- C. Umbilical Hernia
- D. Small upturned nose neonate weighs 3.2 kg, The health care provider prescribes the following orders for the neonate and signs the order sheet. Which order would the nurse question? Progress Notes: 12/01/22- 10am ï‚· Acetaminophen (Tylenol) 10mg/kg per rectum every 4-6 hours prn for pain ï‚· Ampicillin 200mg/kg IV every 6 hours in D5.45 NSSIV @ 125ml/hr. ï‚· Mom may breastfeed ad lib ï‚· Draw blood cultures x 3 in A.M. ï‚· Urine C&S in A.M.
Correct Answer: D
Rationale: The order that the nurse should question is "Ampicillin 200mg./kg IV every 6 hours." The usual dosage for ampicillin is 200-300 mg/kg/day divided into 4-6 doses, not every 6 hours. Administering ampicillin every 6 hours at 200mg/kg could potentially lead to overdose for the neonate. It is important to clarify this dosage with the health care provider before administering the medication to ensure the safety of the newborn.
A client at 28 weeks' gestation reports regular uterine contractions. What is the nurse's priority intervention?
- A. Administer tocolytic medication.
- B. Perform a sterile vaginal examination.
- C. Assess fetal heart rate and contraction pattern.
- D. Encourage ambulation to relieve discomfort.
Correct Answer: C
Rationale: Assessing fetal heart rate and contraction patterns is critical to evaluate the risk of preterm labor.