Nokea
The nurse is educating a client about iron supplements during pregnancy. Which statement indicates understanding?
- A. I should take the supplement with milk to improve absorption.
- B. I should take the supplement with orange juice to improve absorption.
- C. I can stop taking the supplement when I feel better.
- D. I should only take the supplement if I feel fatigued.
Correct Answer: B
Rationale: Vitamin C in orange juice enhances iron absorption, improving its efficacy.
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Which finding during a prenatal visit is most concerning in a client at 32 weeks gestation?
- A. Blood pressure of 120/80 mmHg
- B. Mild lower back pain
- C. Weight gain of 2 pounds in one week
- D. Proteinuria of +2 on a urine dipstick
Correct Answer: D
Rationale: Proteinuria is a potential sign of preeclampsia, requiring evaluation.
The nurse is performing Leopold's maneuvers on a client in labor. What is the primary purpose of this assessment?
- A. Evaluate fetal heart rate.
- B. Determine fetal position and presentation.
- C. Check for uterine contractions.
- D. Assess amniotic fluid volume.
Correct Answer: B
Rationale: Leopold's maneuvers help identify fetal position, presentation, and engagement for labor management.
A nurse is caring for a client who is gravida 3, para 2, and is in active labor. The fetal head is at 3+ station after a vaginal examination. Which of the following actions should the nurse take
- A. Apply fundal pressure.
- B. Observe for the presence of a nuchal cord.
- C. Observe for crowning.
- D. Prepare to administer oxytocin.
Correct Answer: C
Rationale: Observing for crowning is the appropriate action for the nurse to take when the fetal head is at 3+ station after a vaginal examination. Crowning refers to the appearance of the baby's head at the vaginal opening during delivery. This indicates that the baby is descending and will be born soon. It is important for the nurse to be prepared for the actual birth once crowning is observed, as it signifies that the second stage of labor is progressing and delivery is imminent. Applying fundal pressure, observing for a nuchal cord, or preparing to administer oxytocin are not appropriate actions at this stage of labor when crowning has been observed.
A nurse is teaching a client who is 28 weeks of gestation and not up-to date on current immunization. Which of the following immunizations should the nurse inform the client to anticipate receiving following birth?
- A. Pneumococcal
- B. Hepatitis
- C. Human papillomavirus
- D. Rubella
Correct Answer: D
Rationale: The CDC recommends that women who are not up-to-date with the MMR (measles, mumps, rubella) vaccine should receive it immediately postpartum. Rubella, also known as German measles, is particularly important during pregnancy because contracting rubella during pregnancy can lead to serious complications in the baby, such as birth defects and miscarriage. By ensuring the client receives the MMR vaccine postpartum, it helps protect both the mother and any future pregnancies from the risk of rubella infection.
The nurse is caring for a client in active labor with late decelerations on the monitor. What is the priority nursing intervention?
- A. Reposition the client to her side.
- B. Administer IV fluids.
- C. Apply oxygen via face mask.
- D. Notify the healthcare provider.
Correct Answer: A
Rationale: Repositioning improves blood flow and oxygen delivery to the fetus during late decelerations.