Nokea
A nurse in an obstetric clinic is caring for four clients.
The nurse should identify that an intrauterine device is contraindicated for which of the following clients?
- A. A client who has a history of gallbladder disease.
- B. A client who has a positive pregnancy test.
- C. A client who smokes one pack of cigarettes per day.
- D. A client who is nulliparous.
Correct Answer: B
Rationale: An IUD is contraindicated in clients with a positive pregnancy test because it can harm the developing fetus and lead to complications.
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History and Physical: The client reports a history of one previous cesarean section due to breech presentation. She smokes half a pack of cigarettes daily and has a BMI greater than 30. The client denies leakage of amniotic fluid and describes positive fetal movement. Vital Signs: Temperature: 98.6°F (37°C), Pulse: 88 beats/min, Respiratory Rate: 16 breaths/min, Blood Pressure: 128/78 mmHg, Oxygen Saturation: 98% on room air. Nurses' Notes (0830 and 0845): 0830: The client is grimacing and reports discomfort. Fetal heart rate is 148 beats per minute. Fundal height measures 28 cm. 0845: Uterine contractions every 2 to 3 minutes, moderate in intensity, lasting 60 seconds.
The nurse should recommend to first address the client's ___, followed by the client's ___.
- A. Uterine contraction frequency
- B. History of cesarean delivery
Correct Answer: A,B
Rationale: Frequent contractions indicate preterm labor risk at 30 weeks; prior cesarean increases uterine rupture risk, both needing prompt attention.
A nurse is assisting with the care of a newborn who has neonatal abstinence syndrome.
Which of the following actions should the nurse take first?
- A. Swaddle the newborn in blankets.
- B. Weigh the newborn's wet diaper.
- C. Auscultate the newborn's bowel sounds.
- D. Determine the newborn's respiratory rate.
Correct Answer: D
Rationale: Determining the respiratory rate first ensures airway and breathing stability, a critical initial step in managing neonatal abstinence syndrome.
A nurse is caring for a client who inquires about available methods of contraception.
Which of the following actions should the nurse take?
- A. Collect a dietary history.
- B. Assess the client's socioeconomic status.
- C. Perform unbiased teaching.
- D. Select the best method of contraception for the client.
Correct Answer: C
Rationale: Performing unbiased teaching provides comprehensive contraception information, empowering the client to make an informed decision autonomously.
A nurse is caring for a 2-day-old newborn who is undergoing phototherapy for treatment of hyperbilirubinemia.
Which of the following actions should the nurse take?
- A. Provide additional hydration by offering glucose water.
- B. Apply a water-based lotion to the newborn's skin every 4 hours.
- C. Remove the newborn from phototherapy every 2 hours for breastfeeding.
- D. Monitor the newborn's heart rate every 2 hours.
Correct Answer: C
Rationale: Removing the newborn for breastfeeding every 2 hours ensures nutrition and bonding without significantly disrupting phototherapy.
Nurses' Notes (Postpartum Assessment) 1200: The client successfully delivered a viable newborn via vaginal delivery. 1300: The client reports feeling tired and anxious. Assessment reveals the fundus is deviated to the left, boggy, and located 1 cm above the umbilicus. The perineal pad is saturated with lochia rubra, indicating excessive bleeding. The client reports an inability to ambulate to the bathroom due to residual numbness from the labor epidural. Pain is reported as 0 on a scale of 0 to 10. Fundal massage performed during assessment has yielded no improvement in uterine tone. A nurse is caring for a 36-year-old female client in the labor and delivery unit at 39 weeks of gestation admitted for evaluation of postpartum bleeding following a vaginal delivery.
Select the 2 interventions the nurse should perform immediately.
- A. Weigh the client’s perineal pad.
- B. Insert a straight catheter for the client.
- C. Administer methylergonovine 0.2 mg IM.
- D. Draw a complete blood count.
- E. Apply oxygen via nasal cannula.
Correct Answer: B,C
Rationale: Inserting a catheter empties the bladder, aiding uterine contraction; methylergonovine stimulates contractions to reduce bleeding from a boggy uterus.