Nokea
The nurse is caring for a G5 in labor. The membrane
- A. Which nursing action is most important to undertake at this time?
- B. Complete sterile vaginal exam
- C. Assess odor of amniotic fluid
- D. Perform Leopold's maneuver
Correct Answer: A
Rationale: The most important nursing action to undertake at this time is obtaining a fetal heart rate (FHR) assessment. Monitoring the FHR is crucial during labor to assess the well-being of the baby and detect any signs of fetal distress. This information helps guide the healthcare team in determining the appropriate course of action to ensure the safety of both the mother and baby. It takes precedence over other tasks such as completing a sterile vaginal exam, assessing the odor of amniotic fluid, performing Leopold's maneuver, or obtaining pain medication orders. Monitoring the FHR should be the immediate priority in this situation.
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The nurse is conducting a prenatal class about amniotic fluid. Which characteristics should be included in the teaching?
- A. Allows for fetal movement.
- B. Surrounds, cushions, and protects the fetus.
- C. Maintains the body temperature of the fetus.
- D. Can be used to measure fetal kidney function.
Correct Answer: B
Rationale: Amniotic fluid serves multiple functions, including cushioning the fetus, temperature regulation, and monitoring fetal kidney health.
What is the primary nursing action for a newborn experiencing signs of hypoglycemia?
- A. Administer glucose water via a bottle
- B. Feed the newborn breastmilk or formula
- C. Monitor glucose levels and reassess in 30 minutes
- D. Start an IV glucose drip
Correct Answer: B
Rationale: Feeding with breastmilk or formula is the most effective intervention for neonatal hypoglycemia.
What education does the nurse provide to a person taking Ella for emergency contraception?
- A. abstain from sex or use a barrier method for 5 days and then restart their COCs
- B. abstain from sex or use a barrier method until their menses occur and then restart their COCs
- C. restart their COCs the next day; no backup method is needed
- D. restart their COCs the next day and use a backup method for 7 days
Correct Answer: D
Rationale: The education the nurse should provide to a person taking Ella for emergency contraception is to restart their COCs the next day and use a backup method, such as condoms, for 7 days. This is important to ensure continued protection against pregnancy, as Ella may potentially reduce the effectiveness of the COCs. Using a backup method during this time is essential to prevent unintended pregnancy.
What is one characteristic of the Alexander Technique the nurse can explain to a patient?
- A. taught only in person
- B. focused on unmedicated birth
- C. taught by a person who will assess the muscles and posture
- D. only useful for pregnancy but not birth
Correct Answer: C
Rationale: The Alexander Technique involves personalized assessment of posture and muscle tension by a trained instructor.
The nurse teaches a new mother that neonatal weight loss in the first 3 days of life is most often the result of:
- A. Allergy to formula
- B. a hypoglycemic response
- C. Inadequate breast or formula feeding
- D. Excretion of fluid via lungs, urinary bladder and bowels.
Correct Answer: C
Rationale: Neonatal weight loss in the first 3 days of life is most often the result of inadequate breast or formula feeding. During the initial days of life, it is normal for newborn babies to experience some weight loss. This weight loss is generally due to factors such as insufficient intake of breast milk or formula. It takes a few days for a mother's mature breast milk to come in, and during this time, a newborn may not receive enough colostrum, which can lead to initial weight loss. Similarly, if a baby is not getting enough formula or is having feeding difficulties, this can also result in weight loss. Allergy to formula, a hypoglycemic response, or excretion of fluid via lungs, urinary bladder, and bowels are less likely explanations for neonatal weight loss in the first 3 days of life compared to inadequate feeding.