Nokea
The physician orders whole blood replacement for a multigravid client with abruptio placentae. Before administering the intravenous blood product, the nurse should first:
- A. Validate client information and the blood product with another nurse.
- B. Check the vital signs before transfusing over 5 to 6 hours.
- C. Ask the client if she has ever had any allergies.
- D. Administer 100 mL of 5% dextrose solution intravenously.
Correct Answer: A
Rationale: Validating client information and blood product is essential to prevent transfusion errors.
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A 16-year-old primigravid client, with a history of attending one prenatal visit, is admitted to the hospital in active labor at 37 weeks' gestation. Her cervix is 7 cm dilated with the presenting part at 0 station. She enters the labor unit appearing anxious and hyperventilating. Because of the hyperventilation, the nurse should assess the client for:
- A. Metabolic alkalosis.
- B. Metabolic acidosis.
- C. Respiratory alkalosis.
- D. Respiratory acidosis.
Correct Answer: C
Rationale: Hyperventilation causes excessive exhalation of carbon dioxide, leading to respiratory alkalosis (elevated blood pH). Metabolic imbalances are less likely, and respiratory acidosis occurs with hypoventilation.
After explaining to a primiparous client about the causes of her neonate's cranial molding, which of the following statements by the mother indicates the need for further instruction?
- A. The molding was caused by an overlapping of the baby's cranial bones during my labor.'
- B. The amount of molding is related to the amount and length of pressure on the head.'
- C. The molding will usually disappear in a couple of days.'
- D. Brain damage may occur if the molding doesn't resolve quickly.'
Correct Answer: D
Rationale: Cranial molding is a normal process that resolves within days and does not cause brain damage, indicating the mother needs further instruction.
Which of the following instructions about activities during menstruation would the nurse include when counseling an adolescent who has just begun to menstruate?
- A. Take a mild analgesic if needed for menstrual pain.
- B. Avoid cold foods if menstrual pain persists.
- C. Stop exercise while menstruating.
- D. Avoid sexual intercourse while menstruating.
Correct Answer: A
Rationale: Mild analgesics like ibuprofen can effectively manage menstrual pain. There is no evidence supporting avoiding cold foods, and moderate exercise can alleviate cramps. Sexual intercourse during menstruation is a personal choice and not medically contraindicated.
Which of the following would the nurse expect to assess in a neonate delivered at 28 weeks' gestation who is diagnosed with intraventricular hemorrhage (IVH)?
- A. Increased muscle tone.
- B. Hyperbilirubinemia.
- C. Bulging fontanels.
- D. Hyperactivity.
Correct Answer: C
Rationale: Bulging fontanels are a sign of increased intracranial pressure from IVH in preterm neonates.
The nurse is caring for a multigravid client who speaks little English. As the nurse enters the client's room, the nurse observes the client panting on the bed and the fetal head crowning. After calling for assistance and helping the client lie down, which of the following actions should the nurse do next?
- A. Tell the client to push between contractions.
- B. Provide gentle support to the fetal head.
- C. Apply gentle upward traction on the neonate's anterior shoulder.
- D. Massage the perineum to stretch the perineal tissues.
Correct Answer: B
Rationale: With the fetal head crowning, providing gentle support prevents rapid expulsion and perineal trauma. Pushing between contractions is incorrect, traction is for shoulder dystocia, and perineal massage is less urgent.