Nokea
The nurse is caring for a client in the second stage of labor. What finding indicates that birth is imminent?
- A. Cervix is fully dilated.
- B. Contractions every 2 minutes.
- C. Fetal heart rate of 140 beats/minute.
- D. Crowning is observed.
Correct Answer: D
Rationale: Crowning, or the appearance of the fetal head at the vaginal opening, indicates that birth is imminent.
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The nurse is performing an assessment of a postpartum client. Which finding requires immediate action?
- A. Temperature of 100.4°F.
- B. Foul-smelling lochia.
- C. Fundus firm and midline.
- D. Breast tenderness on palpation.
Correct Answer: B
Rationale: Foul-smelling lochia may indicate an infection and requires prompt medical evaluation.
The nurse is caring for a client in active labor with late decelerations on the monitor. What is the priority nursing intervention?
- A. Reposition the client to her side.
- B. Administer IV fluids.
- C. Apply oxygen via face mask.
- D. Notify the healthcare provider.
Correct Answer: A
Rationale: Repositioning improves blood flow and oxygen delivery to the fetus during late decelerations.
In caring for an immediate postpartum client, you note she has
- A. You monitor closely for which clotting disorder? (Which bleeding problem causes this: HEELP
- C. DIC
Correct Answer: A
Rationale: In caring for an immediate postpartum client, you should monitor closely for HELLP syndrome, which stands for Hemolysis, Elevated Liver enzymes, and Low Platelet count. HELLP syndrome is a serious complication of pregnancy characterized by high blood pressure, protein in the urine, and problems with the liver and blood-clotting system. It can lead to severe bleeding issues, organ failure, and other life-threatening complications if not promptly recognized and managed. Therefore, close monitoring for signs of HELLP syndrome is crucial in the postpartum period to ensure timely intervention and prevent adverse outcomes.
A 30-year-old woman is considering the use of emergency contraception. Which of the following is true about its use?
- A. It is most effective when used within 72 hours after unprotected sex.
- B. It should be used at least 5 days after unprotected sex to be effective.
- C. It prevents implantation of a fertilized egg into the uterine wall.
- D. It requires a prescription from a healthcare provider.
Correct Answer: A
Rationale: Emergency contraception is most effective when taken within 72 hours of unprotected sex. Choice B is incorrect as it is not as effective after 5 days. Choice C is incorrect because emergency contraception works primarily by preventing ovulation, not by preventing implantation. Choice D is incorrect because most emergency contraception methods are available over the counter.
The nurse is educating a client about iron supplements during pregnancy. Which statement indicates understanding?
- A. I should take the supplement with milk to improve absorption.
- B. I should take the supplement with orange juice to improve absorption.
- C. I can stop taking the supplement when I feel better.
- D. I should only take the supplement if I feel fatigued.
Correct Answer: B
Rationale: Vitamin C in orange juice enhances iron absorption, improving its efficacy.