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The nurse is reviewing a woman's health care record during her first prenatal visit. The client has a history of chicken pox as a child and syphills as a teenager. Which action is most important for the nurse to take?
- A. Obtain blood and urine for prenatal screens
- B. Explain common complications of pregnancy
- C. Obtain baseline blood pressure and weight
- D. Schedule prenatal visits to occur monthly
Correct Answer: A
Rationale: Given the history of syphilis, obtaining blood and urine for prenatal screens is critical to assess for active infection or other risks that could impact the pregnancy.
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The nurse is performing a newborn assessment. Which symptom, if present in a newborn, would indicate respiratory distress?
- A. Flaring of the nares
- B. Shallow and irregular respirations
- C. Respiratory rate of 50 breaths per minute
- D. Abdominal breathing with synchronous chest movement
Correct Answer: A
Rationale: Flaring of the nares is a specific sign of respiratory distress in newborns, indicating increased effort to breathe. It is more immediate and specific than other options.
A multiparous client with active herpes lesions is admitted to the unit with spontaneous rupture of membranes. Which action should the nurse take?
- A. Prepare for a cesarean section
- B. Cover the lesion with a dressing
- C. Obtain blood cultures
- D. Administer penicillin.
Correct Answer: A
Rationale: Active herpes lesions pose a risk of neonatal herpes transmission during vaginal delivery. Preparing for a cesarean section is the priority to minimize this risk.
A client at 40-weeks gestation presents to the obstetrical floor and indicates that the amniotic membranes ruptured spontaneously at home. She is in active labor, and feels the need to bear down and push. Which information is most important for the nurse to obtain?
- A. Estimated amount of fluid.
- B. Color and consistency of fluid.
- C. Time the membranes ruptured
- D. Any odor noted when membranes ruptured
Correct Answer: C
Rationale: The time of membrane rupture is critical to assess the risk of infection, which increases with prolonged rupture, especially in active labor.
A new mother who is breastfeeding her 4-week-old infant and has type 1 diabetes, reports that her insulin needs have decreased since the birth of her child. Which action should the nurse implement?
- A. Schedule an appointment for the client with the diabetic nurse educator.
- B. Counsel her to increase her caloric intake
- C. Inform her that a decreased need for insulin occurs while breastfeeding
- D. Advise the client to breastfeed more frequently
Correct Answer: C
Rationale: Breastfeeding can lower insulin requirements due to increased energy expenditure, and informing the client of this normal change is appropriate.
A 25-year-old client who had a severe postpartum hemorrhage following the vaginal birth of twins is transferred to the postpartum unit. The nurse knows that assessment for what complication has the highest priority for this client?
- A. Placenta accreta
- B. Hard, painful uterine afterpains.
- C. Postpartum psychosis.
- D. Disseminated intravascular coagulation
Correct Answer: D
Rationale: Severe postpartum hemorrhage increases the risk of disseminated intravascular coagulation (DIC), a life-threatening condition requiring urgent assessment.