Nokea
The nurse is caring for a client who delivered 6 hours ago. Assessment findings reveal a boggy uterus that is displaced above and to the right of the umbilicus. Which action should the nurse take?
- A. Encourage voiding
- B. Notify healthcare provider
- C. Inspect the perineal pad
- D. Monitor vital signs
Correct Answer: A
Rationale: A boggy uterus displaced above and to the right of the umbilicus often indicates a distended bladder, which can prevent proper uterine contraction. Encouraging voiding addresses this issue, helping the uterus return to its normal position and firm up.
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A multiparous client with active herpes lesions is admitted to the unit with spontaneous rupture of membranes. Which action should the nurse take?
- A. Prepare for a cesarean section
- B. Cover the lesion with a dressing
- C. Obtain blood cultures
- D. Administer penicillin.
Correct Answer: A
Rationale: Active herpes lesions pose a risk of neonatal herpes transmission during vaginal delivery. Preparing for a cesarean section is the priority to minimize this risk.
What instruction is most important for the nurse to provide a client in the first trimester of pregnancy who is experiencing nausea?
- A. Avoid alcohol, caffeine, and smoking.
- B. Eliminate between meal snacks
- C. Practice relaxation techniques when the nausea first begins
- D. Increase intake of fluids to 3 quarts daily
Correct Answer: C
Rationale: Relaxation techniques like deep breathing can help manage nausea, especially if triggered by stress or anxiety, making it the most effective immediate intervention.
The nurse receives a newborn within the first minutes after a vaginal delivery and intervenes to establish adequate respirations. What priority issue should the nurse address to ensure the newborn's survival?
- A. Bleeding tendencies
- B. Heat loss
- C. Hypoglycemia
- D. Fluid balance
Correct Answer: B
Rationale: Newborns are at high risk for hypothermia due to heat loss, which can compromise survival. Preventing heat loss is a priority immediately after birth.
The nurse is caring for a client whose fetus died in utero at 32-weeks gestation. After the fetus is delivered vaginally, the nurse implements routine fetal demise protocol and identification procedures Which action is most important for the nurse to take?
- A. Explain reasons consent for an infant autopsy is needed
- B. Determine if the mother desires a visit from her clergy
- C. Encourage the mother to hold and spend time with her baby
- D. Create a memory box of baby's footprints and photographs
Correct Answer: C
Rationale: Encouraging the mother to hold and spend time with her baby supports the grieving process, helping her acknowledge and create memories with her child.
The nurse is assessing a 38-week gestation newborn infant immediately following a vaginal birth. Which assessment finding best indicates that the infant is transitioning well to extrauterine life?
- A. Cries vigorously when stimulated
- B. A positive Babinski reflex
- C. Heart rate of 220 beats/minute
- D. Flexion of all four extremities
Correct Answer: A
Rationale: Vigorous crying indicates effective breathing and responsiveness, key signs of successful transition to extrauterine life.