Nokea
The nurse receives a newborn within the first minutes after a vaginal delivery and intervenes to establish adequate respirations. What priority issue should the nurse address to ensure the newborn's survival?
- A. Bleeding tendencies
- B. Heat loss
- C. Hypoglycemia
- D. Fluid balance
Correct Answer: B
Rationale: Newborns are at high risk for hypothermia due to heat loss, which can compromise survival. Preventing heat loss is a priority immediately after birth.
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A pregnant client receives Rho(D) immune globulin after an amniocentesis. The day following the procedure the client calls the nurse to report a temperature of 99.8° F (37.67°C). Which action should the nurse implement?
- A. Instruct the client to maintain bed rest for 24 hours.
- B. Encourage the client to increase her intake of oral fluids
- C. Schedule a visit with the healthcare provider today
- D. Verify the administered Rho(D) immune globulin's compatibility
Correct Answer: C
Rationale: A temperature elevation post-amniocentesis may indicate infection, requiring prompt evaluation by a healthcare provider.
Assessment findings of a 4-hour-old newborn include: axillary temperature of 96.8° F (35.8° C), heart rate of 150 beats/minute with a soft murmur, irregular respiratory rate at 64 breaths/minute, jitteriness, hypotonic and weak cry. Based on these findings, which action should the nurse implement?
- A. Document the findings in the record
- B. Obtain a heel stick blood glucose level.
- C. Place a pulse oximeter on the heel.
- D. Swaddle the infant in a warm blanket
Correct Answer: B
Rationale: Jitteriness, hypotonia, and a weak cry suggest possible hypoglycemia, a critical condition requiring immediate blood glucose testing.
The nurse examines a client who is admitted in active labor and determines the cervix is 3 cm dilated 50% effaced, and the presenting part is at 0 station. An hour later. she tells the nurse that she wants to go to the bathroom. Which action should the nurse implement first?
- A. Review the fetal heart rate pattern
- B. Check the pH of the vaginal fluid
- C. Determine cervical dilation.
- D. Palpate the client's bladder
Correct Answer: D
Rationale: A desire to use the bathroom may indicate a full bladder, which can impede labor progress. Palpating the bladder is the priority to assess this.
A 16-year-old gravida 1, para 0 client has just been admitted to the hospital with a diagnosis of eclampsia. She is not presently convulsing Which intervention should the nurse plan to include in this client's nursing care plan?
- A. Monitor blood pressure pulse, and respirations every 4 hour
- B. Keep an airway at the bedside
- C. Allow liberal family visitation
- D. Assess temperature every hour
Correct Answer: B
Rationale: Eclampsia can lead to seizures, making airway management equipment critical to ensure safety during a potential seizure event.
A client who had her first baby three months ago and is breastfeeding her infant tells the nurse that she is currently using the same diaphragm that she used before becoming pregnant. Which information should the nurse provide this client?
- A. After ceasing breastfeeding the diaphragm should be resized.
- B. Use an alternate form of contraception until a new diaphragm is obtained.
- C. If no more than 20 pounds was gained during pregnancy, the diaphragm is safe to use.
- D. Avoid intercourse during ovulation until the size of the diaphragm has been evaluated
Correct Answer: B
Rationale: Pregnancy and childbirth can alter vaginal anatomy, making a pre-pregnancy diaphragm ineffective. An alternate contraception method is needed until a new diaphragm is fitted.