Nokea
The nurse is performing Leopold's maneuvers on a pregnant client. What is the primary purpose?
- A. Assess fetal heart tones.
- B. Determine fetal position.
- C. Evaluate amniotic fluid volume.
- D. Check for uterine contractions.
Correct Answer: B
Rationale: Leopold's maneuvers help determine the position and presentation of the fetus within the uterus.
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What are the modes of heat loss in babies? SATA
- A. Radiation
- B. Conduction
- C. Convection
- D. Perspiration (baby's don't perspir
Correct Answer: A
Rationale: A. Radiation: Heat loss through radiation occurs when the baby is near a cold surface or in a drafty room, causing heat to transfer from the baby's body to the surrounding environment.
Which statement by the patient helps the nurse know
- A. Follicle-stimulating hormone she understands the teaching about condom use?
- B. Gonadotropin-releasing hormone
- C. A condom can be worn for two sexual encounters
- D. Progesterone as long as it does not break.
Correct Answer: A
Rationale: The statement "Condoms come in different sizes; it is important I get the right size to ensure proper protection" indicates that the patient understands the teaching about condom use. This statement shows an understanding of the importance of choosing the appropriate condom size for effective protection during sexual encounters. It reflects the patient's grasp of the information provided by the nurse regarding condom use, which is crucial in promoting safe practices to prevent sexually transmitted infections and unintended pregnancies.
A nurse is caring for a client who is 4 hr postpartum following a vaginal birth. The client has saturated a perineal pad within 10 min. Which of the following actions should the nurse take first
- A. Assess client's blood pressure.
- B. Assess the bladder for distention.
- C. Massage the client's fundus.
- D. Prepare to administer a prescribed oxytocic preparation.
Correct Answer: B
Rationale: The first action the nurse should take in this situation is to assess the bladder for distention. Postpartum hemorrhage can be caused by a distended bladder putting pressure on the uterus, preventing it from contracting effectively and leading to excessive bleeding. By assessing for bladder distention and ensuring the client empties her bladder, the nurse can help the uterus contract more efficiently and potentially reduce the bleeding. Assessing the other options such as blood pressure, massaging the fundus, and preparing to administer an oxytocic can be important interventions eventually, but addressing the bladder distention is the first priority in this case of excessive postpartum bleeding.
The nurse is assessing a client at 10 weeks' gestation. Which finding is expected?
- A. Quickening.
- B. Fetal heart tones by Doppler.
- C. Fundus at the level of the umbilicus.
- D. Presence of Braxton Hicks contractions.
Correct Answer: B
Rationale: Fetal heart tones can typically be detected by Doppler around 10 weeks' gestation.
A nurse is planning care for a newborn who is scheduled to start phototherapy using a lamp. Which of the following actions should the nurse include in the plan?
- A. Apply a thin layer of lotion to the newborn skin every 8 hrs.
- B. Give the newborn 1oz of glucose water every 4 hrs.
- C. Ensure the newborn eyes are closed beneath the shield.
- D. Dress the newborn in a thin layer of clothing during therapy
Correct Answer: C
Rationale: The correct action the nurse should include in the care plan for a newborn undergoing phototherapy using a lamp is to ensure that the newborn's eyes are closed beneath the shield. This is important to protect the newborn's eyes from exposure to the bright light emitted during phototherapy, as prolonged exposure can lead to eye damage. Keeping the eyes closed under the shield helps prevent potential harm and ensures the safety and well-being of the newborn during the treatment. Applying a thin layer of lotion, giving glucose water, or dressing the newborn in clothing are not relevant or appropriate actions for phototherapy care in this scenario.