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The nurse notices that a client who has just delivered her infant is short of breath, ashen in color, and begins to cough. She becomes limp on the delivery table. Determine the nursing actions in the order they should occur.
- A. Open airway using head tilt-chin lift.
- B. Ask staff to activate emergency response system.
- C. Establish unresponsiveness.
- D. Give 2 breaths.
- E. Check the pulse.
Correct Answer: C,A,D,E,B
Rationale: Assess responsiveness first, then secure the airway, breathing, and circulation.
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While the nurse is preparing to assist the primiparous client to the bathroom to void 6 hours after a vaginal delivery under epidural anesthesia, the client says that she feels dizzy when sitting up on the side of the bed. The nurse explains that this is most likely caused by which of the following?
- A. Effects of the anesthetic during labor.
- B. Hemorrhage during the delivery process.
- C. Effects of analgesics used during labor.
- D. Decreased blood volume in the vascular system.
Correct Answer: A
Rationale: Dizziness when sitting up is likely due to residual effects of epidural anesthesia, which can cause orthostatic hypotension.
As a nurse begins her shift on the obstetrical unit, there are several new admissions. The client with which of the following conditions would be a candidate for induction?
- A. Pregnancy-induced hypertension (PIH).
- B. Active herpes.
- C. Face presentation.
- D. Fetus with late decelerations.
Correct Answer: A
Rationale: Pregnancy-induced hypertension (PIH) is an indication for induction to prevent maternal-fetal complications. Active herpes, face presentation, or late decelerations are contraindications due to risks of infection, dystocia, or fetal distress.
The nurse is caring for a primiparous client and her neonate immediately after delivery. The neonate was born at 41 weeks' gestation and weighs 4,082 g (9 lb). Assessing for signs and symptoms of which of the following conditions should be a priority in the neonate?
- A. Anemia.
- B. Hypoglycemia.
- C. Delayed meconium.
- D. Elevated bilirubin.
Correct Answer: B
Rationale: Large-for-gestational-age neonates (e.g., 4,082 g) are at risk for hypoglycemia due to increased metabolic demand and potential maternal diabetes. Hypoglycemia screening is a priority. Anemia, delayed meconium, or hyperbilirubinemia are less immediate.
The nurse is to draw a blood sample for glucose testing from a term neonate during the first hour after birth. The nurse should obtain the blood sample from the neonate's foot near which of the following areas?
Correct Answer: B
Rationale: The blood sample should be obtained from the lateral or medial heel of the neonate's foot to minimize pain and avoid major nerves and blood vessels.
A nurse is counseling a client about the fertility awareness method. Which of the following client statements indicates a need for further teaching?
- A. I will track my basal body temperature daily.
- B. I will monitor my cervical mucus for changes.
- C. I will avoid intercourse during my fertile days.
- D. I can rely on this method even with irregular cycles.
Correct Answer: D
Rationale: The fertility awareness method is less reliable with irregular cycles, as ovulation is harder to predict. The other statements reflect correct understanding, indicating a need for further teaching about cycle regularity.