Nokea
The nurse notes on the fetal monitor that a laboring client has a variable deceleration. Which action should the nurse implement first?
- A. Administer oxygen via facemask.
- B. Turn off the oxytocin infusion
- C. Assess cervical dilatation
- D. Change the client's position
Correct Answer: D
Rationale: Variable decelerations often result from umbilical cord compression. Changing the client's position, such as to a lateral or knee-chest position, is the first step to relieve this.
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During a routine first trimester prenatal exam, a pregnant client tells the nurse that she has noticed an increase in vaginal discharge that is white, thin, and watery. Which action should the nurse implement?
- A. Notify the healthcare provider of the complaint
- B. Recommend an over-the-counter yeast medication
- C. Inform her that this is a normal physiological change.
- D. Prepare the client for a sterile speculum exam
Correct Answer: C
Rationale: Increased white, thin, watery discharge (leukorrhea) is a normal physiological change in pregnancy due to hormonal shifts, requiring no immediate intervention.
The healthcare provider prescribes magnesium sulfate 6 grams intravenously (IV) to be infused over 20 minutes for client with preterm labor. The IV bag contains magnesium sulfate 20 grams in dextrose 5% in water 500 mL. How many mL/hour should the nurse set the infusion pump? (Enter numerical value only.)
Correct Answer: 450
Rationale: To deliver 6 grams over 20 minutes from a solution of 20 grams in 500 mL, the concentration is 25 mL/g. Thus, 6 grams requires 150 mL over 20 min, which is (150 mL / 20 min) x 60 = 450 mL/hour.
A client is admitted to the postpartum unit and tells the nurse she had rheumatic fever as a child, which resulted in some 'heart damage.' The nurse knows that this client is at particular risk for developing heart failure during the immediate postpartum period. Based on this client's history, which nursing problem has the highest priority?
- A. Sleep deprivation.
- B. Fluid volume excess
- C. Nausea and vomiting
- D. Risk for infection.
Correct Answer: B
Rationale: Heart damage from rheumatic fever increases the risk of heart failure, particularly postpartum due to fluid shifts. Managing fluid volume excess is the priority.
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.
The nurse is caring for a client who delivered 6 hours ago. Assessment findings reveal a boggy uterus that is displaced above and to the right of the umbilicus. Which action should the nurse take?
- A. Encourage voiding
- B. Notify healthcare provider
- C. Inspect the perineal pad
- D. Monitor vital signs
Correct Answer: A
Rationale: A boggy uterus displaced above and to the right of the umbilicus often indicates a distended bladder, which can prevent proper uterine contraction. Encouraging voiding addresses this issue, helping the uterus return to its normal position and firm up.