Nokea
The physician performs an amniotomy for a woman in labor. Which nursing action should follow the procedure?
- A. Check the client's capillary refill and oxygenation.
- B. Monitor the maternal pulse and blood pressure.
- C. Inspect the perineum for lacerations, bleeding, and hematoma.
- D. Assess the fluid for color, odor, and amount.
Correct Answer: D
Rationale: The correct answer is D: Assess the fluid for color, odor, and amount. After an amniotomy, it is important to assess the amniotic fluid to ensure it is clear, odorless, and of the appropriate amount, as changes in these characteristics may indicate fetal distress or infection. Checking capillary refill and oxygenation (Choice A) is not directly related to an amniotomy. Monitoring maternal pulse and blood pressure (Choice B) is important but not the immediate priority post-amniotomy. Inspecting the perineum for lacerations, bleeding, and hematoma (Choice C) is important for overall assessment but not specific to the procedure.
You may also like to solve these questions
A child diagnosed with asthma begins corticosteroid treatments. The nurse explains to the parents that the purpose of corticosteroid treatment is to produce which therapeutic effect?
- A. Dilation of bronchial airways
- B. Decrease bronchospasms
- C. Prevention of infection
- D. Anti-inflammatory effect
Correct Answer: D
Rationale: Corticosteroid usage is common for decreasing inflammation of the bronchial airways. While dilation of bronchial airways and decrease in bronchospasms are effects of other medications like albuterol and beta-2 agonists, corticosteroids specifically target inflammation, which is a key component in managing chronic asthma.
A women in her first trimester contracts rubella. How is the fetus likely to be affected?
- A. Reproductive and urinary defects
- B. Heart defects and cataracts
- C. Spinal cord and skeletal defects
- D. Polydactyly and club feet
Correct Answer: B
Rationale: The correct answer is B: Heart defects and cataracts. Rubella infection during the first trimester can lead to congenital rubella syndrome, causing heart defects and cataracts in the fetus. Rubella affects organ development during this critical period. Choice A is incorrect as rubella does not typically cause reproductive and urinary defects. Choice C is incorrect because rubella does not usually result in spinal cord and skeletal defects. Choice D is incorrect as polydactyly and club feet are not typical manifestations of rubella infection during pregnancy.
A client in active labor receives a regional anesthetic. Which is the main purpose of regional anesthetics?
- A. To relieve pain by decreasing the client's level of consciousness
- B. To provide general loss of sensation by blocking sensory nerves to an area
- C. To provide pain relief by blocking descending impulses from the central nervous system
- D. To relieve pain by decreasing the perception of pain leading to the pain centers in the brain
Correct Answer: B
Rationale: The correct answer is B: To provide general loss of sensation by blocking sensory nerves to an area. Regional anesthetics work by blocking specific nerve pathways in a targeted area, leading to loss of sensation while maintaining consciousness. This is ideal for laboring clients as it allows pain relief without affecting consciousness or motor function. Choice A is incorrect as regional anesthetics do not aim to decrease consciousness. Choice C is incorrect as regional anesthetics block sensory nerves locally, not descending impulses. Choice D is incorrect as the goal is to block sensation locally, not perception in the brain.
The nursery nurse delays the first bottle feeding of a newborn. Which is the most common reason for the nurse's actions? The infant has:
- A. a blood glucose of 45 gm/dL
- B. a respiratory rate above 60
- C. blue hands and feet
- D. a heart murmur
Correct Answer: B
Rationale: The correct answer is B: a respiratory rate above 60. The nurse delays feeding because a high respiratory rate may indicate respiratory distress, making feeding unsafe. Feeding can lead to aspiration in infants with respiratory issues. A blood glucose of 45 gm/dL (choice A) is low but not typically a reason to delay feeding. Blue hands and feet (choice C) may indicate poor circulation, but it's not a common reason to delay feeding. A heart murmur (choice D) doesn't directly impact feeding safety.
A 17-year-old client delivered her first baby 8 hours ago. Which of the following is an indication that appropriate bonding is occurring? The client:
- A. makes eye contact with the baby.
- B. wonders why the baby cries so much.
- C. asks the nurse to help change the baby's diaper.
- D. asks the nurse if the baby is cute.
Correct Answer: A
Rationale: The correct answer is A: makes eye contact with the baby. This indicates appropriate bonding as eye contact fosters emotional connection and attachment between mother and baby. It shows the mother is engaging with her child, seeking to establish a bond. Choice B suggests lack of understanding of infant communication, choice C indicates practical caregiving rather than emotional bonding, and choice D focuses on the baby's appearance rather than emotional connection.