Nokea
The nurse is monitoring a client in the second stage of labor. What finding indicates the client is ready to push?
- A. Membranes have ruptured.
- B. Cervix is completely dilated.
- C. Client reports back pain.
- D. Contractions are 10 minutes apart.
Correct Answer: B
Rationale: Complete cervical dilation marks the beginning of the second stage, signaling readiness to push.
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The nurse is attempting to explain physiologic birth. What do they say?
- A. Physiologic birth involves interventions that do not harm the baby.â€
- B. Physiologic birth occurs only in birth centers.â€
- C. If your partner and I give you support, you can have a birth without medical intervention.â€
- D. If you want to have a cesarean birth, we can ask your health-care provider to schedule it.â€
Correct Answer: C
Rationale: Physiologic birth focuses on minimal intervention, supported by a calm environment and supportive care.
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.
A client is admitted to the emergency room with a respiratory rate of 7/min. Arterial blood gases (ABG) reveal the following values. Which of the following is an appropriate analysis of the ABGs? pH 7.22, PaCO2 68 mm Hg, Base excess -2, PaO2 78 mm Hg, Saturation 80%, Bicarbonate 26 mEq/L
- A. Respiratory acidosis
- B. Metabolic acidosis
- C. Metabolic alkalosis
- D. Respiratory alkalosis
Correct Answer: A
Rationale: The ABG values provided indicate respiratory acidosis. In respiratory acidosis, there is an increase in PaCO2 above the normal range (35-45 mm Hg) leading to a decrease in pH (<7.35). In this case, the pH is 7.22 (below normal) with an elevated PaCO2 of 68 mm Hg. The other values do not suggest metabolic acidosis (which would typically show low bicarbonate levels) or metabolic alkalosis. Therefore, the correct interpretation of the ABGs is respiratory acidosis.
The breastfeeding mother should be taught a safe method to remove the breast from the baby's mouth? Which suggestion by the nurse is most appropriate?
- A. Break suction by inserting finger into corner of the infant mouth
- B. Elicit the moro reflex
- C. A popping sound
- D. Slowly remove breast from baby's mouth when the infant's mouth
Correct Answer: A
Rationale: The most appropriate suggestion by the nurse is to break the suction by gently inserting a clean finger into the corner of the infant's mouth. This method will safely release the baby's latch without causing any discomfort or injury to the baby or the mother. It is important to break the suction before removing the breast to prevent any potential damage to the nipple and promote a smooth breastfeeding experience for both the mother and the baby. This technique is commonly recommended in breastfeeding education to ensure proper latch and prevent nipple trauma.
A nurse is caring for a client who is 1 day postpartum and is taking a sitz bath. To determine the client's tolerance of the procedure, which of the following assessments should the nurse perform?
- A. Bladder distention
- B. Pulse rate
- C. Respiratory rate
- D. Color of lochia
Correct Answer: B
Rationale: The nurse should assess the client's pulse rate to determine the client's tolerance of the sitz bath. An elevated pulse may indicate that the sitz bath is causing discomfort or stress to the client. Monitoring the pulse rate is essential to ensure the client's safety and comfort during the procedure. Bladder distention, respiratory rate, and color of lochia are important assessments in postpartum care but are not specifically related to determining the client's tolerance of a sitz bath.