Nokea
The nurse is performing Leopold's maneuvers. What is the primary goal?
- A. Determine fetal well-being.
- B. Assess fetal position and presentation.
- C. Measure amniotic fluid volume.
- D. Evaluate uterine contractions.
Correct Answer: B
Rationale: Leopold's maneuvers are used to assess fetal position, presentation, and engagement.
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The nurse is educating a client with gestational hypertension about home care. What instruction should the nurse include?
- A. Monitor your blood pressure once a week.
- B. Report any sudden swelling or weight gain.
- C. Increase sodium intake to maintain hydration.
- D. Avoid taking daily medications.
Correct Answer: B
Rationale: Sudden swelling or rapid weight gain may indicate worsening gestational hypertension or preeclampsia.
Which factor should alert the nurse for the potential of a prolapsed umbilical cord?
- A. Presenting part at station minus 3 (too much empty space in between)
- B. Meconium stained amniotic fluid
- C. Pregnancy at 38 weeks' gestation
- D. Oligohydramnios
Correct Answer: A
Rationale: A presenting part at station minus 3 indicates that there is too much empty space between the presenting part (usually the fetus's head) and the pelvic inlet. This increased space raises the potential for the umbilical cord to prolapse through the cervix and into the birth canal ahead of the baby, especially when the membranes rupture. A prolapsed umbilical cord is a severe obstetric emergency that can cause fetal compromise due to umbilical cord compression and compromise of blood flow. It requires immediate intervention to relieve the pressure on the cord and increase the likelihood of a safe delivery. Therefore, a presenting part at station minus 3 should alert the nurse to the potential of a prolapsed umbilical cord.
To prevent breast engorgement a new breastfeeding mother should be instructed to:
- A. Apply cold packs to the breast before feeding
- B. Breastfeed frequently and for adequate lengths of time to empty the breasts.
- C. Limit her intake of fluids for a few days
- D. Feed her infant no more than every 4 hours
Correct Answer: B
Rationale: Frequent breastfeeding helps prevent engorgement.
The nurse is caring for a 12-year-old child hospitalized for internal injuries following a motor vehicle accident. For which medical treatment would the nurse ensure that an informed consent is completed beyond the one signed at admission?
- A. Diagnostic imaging
- B. Cardiac monitoring
- C. Blood testing
- D. Spinal tap
Correct Answer: D
Rationale: Certain procedures, however, require a specific process of informed consent, including major and minor surgery; invasive procedures such as lumbar puncture or bone marrow aspiration; treatments placing the child at higher risk, such as chemotherapy or radiation therapy; procedures or treatments involving research; photography involving children; and applying restraints to children.
The nurse is caring for a 2-week-old girl with a metabolic disorder. Which activity would deviate from the characteristics of family-centered care?
- A. Softening unpleasant information or prognoses
- B. Evaluating and changing the nursing plan of care
- C. Collaborating with the child and family as equals
- D. Showing respect for the family's beliefs and wishes
Correct Answer: A
Rationale: Family-centered care requires that the nurse provide open and honest information to the child and family. It is inappropriate to soften unpleasant information or prognoses.