Nokea
The nurse is preparing a client for an amniocentesis. What is the priority nursing action?
- A. Verify signed informed consent.
- B. Administer prescribed analgesics.
- C. Encourage the client to empty their bladder.
- D. Position the client in a semi-Fowler's position.
Correct Answer: A
Rationale: Ensuring informed consent is signed is a critical step before an invasive procedure like amniocentesis.
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A nurse in the labor and delivery unit is caring for a client who is undergoing external fetal monitoring. The nurse observes that the fetal heart rate begins to slow after the start of a contraction and the lowest rate occurs after the peak of the contraction. Which of the following actions should the nurse take first?
- A. Place the client in the lateral position.
- B. Increase the rate of maintenance IV infusion.
- C. Elevate the client's legs.
Correct Answer: A
Rationale: The priority action for a nurse to take when observing a slowing of the fetal heart rate after the start of a contraction, with the lowest rate occurring after the peak of the contraction, is to place the client in the lateral position. This position, specifically the left lateral position, can alleviate pressure on the vena cava, improve blood flow to the placenta, and help optimize fetal oxygenation. By changing the client's position, the nurse can potentially relieve the decelerations seen in the fetal heart rate and promote better oxygenation for the fetus. This intervention is effective and can be quickly implemented in a labor and delivery setting to support fetal well-being.
What is the theory that supports HypnoBirthing?
- A. the fear-tension-pain theory
- B. the theory that pain is productive in labor
- C. the idea that self-hypnosis always works if you try hard enough
- D. the theory that when hypnotized during labor, the environment does not matter because the person is not aware of the surroundings
Correct Answer: A
Rationale: HypnoBirthing is based on the fear-tension-pain theory, which links fear to increased tension and pain.
The nurse suspects that a client has an early sign of ectopic
- B. Abdominal pain
- C. Vaginal spotting or light bleeding
- D. Pelvic pain
Correct Answer: C
Rationale: Vaginal spotting or light bleeding is one of the early signs of an ectopic pregnancy. Ectopic pregnancy occurs when a fertilized egg implants outside the uterus, most commonly in the fallopian tube. The presence of vaginal spotting or light bleeding may indicate the implantation of the fertilized egg in a location other than the uterus, leading to the suspicion of an ectopic pregnancy. It is essential for the nurse to recognize this early sign and promptly assess the client for further evaluation and intervention to prevent complications such as rupture and severe bleeding that can be life-threatening.
A nurse is caring for four newborns. Which of the following newborns should the nurse assess first?
- A. Newborn who has nasal flaring
- B. Newborn who has subconjunctival hemorrhage of the left eye
- C. A newborn who has overlapping suture lines
- D. A newborn who has not rust-stained urine
Correct Answer: A
Rationale: Nasal flaring in a newborn can be a sign of respiratory distress, which is a critical condition that requires immediate attention. It indicates that the newborn is having difficulty breathing and may not be getting enough oxygen. This can be due to various reasons such as lung problems, infections, or other respiratory issues. Therefore, the nurse should assess and address the newborn with nasal flaring first to ensure their breathing is stable and adequate.
The nurse is caring for a client in the second stage of labor. What assessment indicates that birth is imminent?
- A. Cervix is dilated to 8 cm.
- B. Fetal head is crowning.
- C. Contractions every 3–5 minutes.
- D. Client reports back pain.
Correct Answer: B
Rationale: Crowning occurs when the fetal head becomes visible at the vaginal opening, indicating that birth is imminent.