Nokea
The nurse is catheterizing a client who cannot void after a normal delivery 8 hours ago. The nurse begins the catheterization process and the client asks the nurse if Betadine was used to clean the meatus for the catheterization. The nurse realizes that the client is allergic to Betadine and the client is reacting to the cleansing agent. The nurse should take the following steps in order of priority from first to last.
- A. Document incident.
- B. Clean Betadine from client's vaginal area.
- C. Notify physician ordering catheterization.
- D. Ask client what her reaction is when exposed to Betadine.
- E. File an incident report.
Correct Answer: B,D,C,A,E
Rationale: First, clean the Betadine to stop the reaction, ask about the reaction to assess severity, notify the physician, document the incident, and file an incident report.
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Which of the following would alert the nurse to suspect that a neonate delivered at 34 weeks' gestation who is currently in an isolette with humidified oxygen and receiving intravenous fluids has developed overhydration?
- A. Hypernatremia.
- B. Polycythemia.
- C. Hypoproteinemia.
- D. Increased urine specific gravity.
Correct Answer: C
Rationale: Hypoproteinemia can result from overhydration, as excess fluid dilutes plasma proteins.
A laboring client smiles pleasantly at the nurse when asked simple questions. The client speaks no English and the interpreter is busy with an emergency situation. At her last vaginal examination, the client was 5 cm dilated, 100% effaced, and at 0 station. While working with this client, which of the following responses indicates that the client may be approaching delivery?
- A. The fetal monitor strip shows late decelerations.
- B. The client begins to speak to her family in her native language.
- C. The fetal monitor strip shows early decelerations.
- D. The client's facial expressions become animated.
Correct Answer: D
Rationale: Animated facial expressions (e.g., grimacing, distress) may indicate transition or second-stage labor, suggesting imminent delivery. Late decelerations indicate fetal distress, speaking to family is nonspecific, and early decelerations are normal.
After a dilatation and curettage(D&C) to evacuate a molar pregnancy, assessing the client for signs and symptoms of which of the following would be most important?
- A. Urinary tract infection.
- B. Hemorrhage.
- C. Abdominal distention.
- D. Chorioamnionitis.
Correct Answer: B
Rationale: Hemorrhage is a potential complication after D&C.
While the nurse is caring for a primiparous client with cephalopelvic disproportion 4 hours after a cesarean delivery, the client requests assistance in breast-feeding. To promote maximum maternal comfort, which of the following would be most appropriate for the nurse to suggest?
- A. Football hold.
- B. Scissors hold.
- C. Cross-cradle hold.
- D. Cradle hold.
Correct Answer: A
Rationale: The football hold minimizes pressure on the cesarean incision, promoting comfort during breastfeeding.
Which of the following should the nurse include in the discharge teaching for a primiparous client about preventing postpartum infections?
- A. Change perineal pads every 8 hours.
- B. Take warm sitz baths twice daily.
- C. Wash hands before and after perineal care.
- D. Use a hairdryer to dry the perineal area.
Correct Answer: C
Rationale: Hand washing before and after perineal care reduces the risk of introducing pathogens, preventing infections.