Nokea
The nurse is monitoring a client in labor who is receiving oxytocin. What finding requires immediate intervention?
- A. Contractions lasting 90 seconds.
- B. Contractions every 2–3 minutes.
- C. Fetal heart rate of 100 beats/minute.
- D. Maternal heart rate of 85 beats/minute.
Correct Answer: C
Rationale: A fetal heart rate of 100 bpm indicates bradycardia, which may signify fetal distress and requires immediate action.
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A woman delivered a baby 9lbs 10oz 1 hour ago. When you
arrive to perform a 15-minute assessment she tells you that she feels
all wet underneath. You discover that both pads are completely
saturated and that she’s lying in a 6-inch diameter of blood. What
does nurse do first
- A. Assess the fundus for firmness
- B. Change the patient's pads
- C. Notify the provider
- D. Document the findings
Correct Answer: A
Rationale: In this scenario, the priority action for the nurse to take is to assess the source of the woman's feeling of wetness underneath her. This could indicate a significant amount of postpartum bleeding, also known as hemorrhage. It is crucial to determine if she is experiencing excessive bleeding as this can be life-threatening if not addressed promptly. By identifying the source of the wetness, the nurse can assess the situation and take appropriate actions to address any potential complications. Once the severity of bleeding is determined, further assessments and interventions can be initiated accordingly.
The menstrual phase of the menstrual cycle is characterized by what?
- A. shedding of the endometrial lining
- B. ovulation
- C. fertilization
- D. implantation
Correct Answer: A
Rationale:
The APGAR is performed at what minutes?
- A. 1 and 5
- B. 2 and 4
- C. 5 and 10
- D. At birth and 5 minutes
Correct Answer: A
Rationale: The APGAR score is a quick assessment tool used to evaluate a newborn's health and overall condition immediately after birth and again at 5 minutes after birth. The five categories evaluated in the APGAR score are Appearance, Pulse, Grimace, Activity, and Respiration. The assessment is typically done at 1 minute and 5 minutes after birth to quickly determine if the baby needs any immediate medical attention or interventions. The scores at both time points provide valuable information about the baby's well-being and can guide healthcare providers in deciding on appropriate next steps for care.
The nurse is monitoring a client with severe preeclampsia. What assessment finding indicates worsening condition?
- A. Proteinuria of +1.
- B. Respiratory rate of 16 breaths per minute.
- C. New-onset confusion and restlessness.
- D. Urine output of 40 mL/hr.
Correct Answer: C
Rationale: New-onset confusion and restlessness may indicate cerebral edema or impending eclampsia.
What is the most appropriate action for a nurse when a newborn has jaundice on the second day of life?
- A. Increase fluid intake of the mother
- B. Phototherapy
- C. Monitor bilirubin levels
- D. Refer to a pediatric specialist
Correct Answer: B
Rationale: Phototherapy helps treat jaundice by breaking down bilirubin.