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A nurse is assessing a client who is 1 hr postpartum following a vaginal birth. The nurse notes that the client has excessive vaginal bleeding. Which of the following actions should the nurse take first?
- A. Massage the client's fundus.
- B. Administer oxytocin to the client.
- C. Empty the client’s bladder.
- D. Provide oxygen to the client via nonrebreather face mask.
Correct Answer: A
Rationale: The correct action is to massage the client's fundus first. This helps to stimulate uterine contractions and control excessive bleeding, preventing postpartum hemorrhage. Massaging the fundus promotes the expulsion of clots and helps the uterus contract, decreasing the risk of further bleeding. Administering oxytocin (choice B) can be done after fundal massage to enhance uterine contractions. Emptying the client's bladder (choice C) can also aid in reducing uterine atony but is not the priority in this situation. Providing oxygen (choice D) is not directly related to controlling postpartum bleeding.
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A nurse is developing a plan of care for a newborn who is to undergo phototherapy for hyperbilirubinemia. Which of the following actions should the nurse include in the plan?
- A. Feed the newborn 1 oz of water every 4 hr.
- B. Apply lotion to the newborn’s skin three times per day.
- C. Remove all clothing from the newborn except the diaper.
- D. Discontinue therapy if the newborn develops a rash.
Correct Answer: C
Rationale: The correct answer is C: Remove all clothing from the newborn except the diaper. This is essential during phototherapy to maximize the skin's exposure to the light. The light helps breakdown bilirubin in the skin, reducing jaundice. Choice A is incorrect as water will not treat hyperbilirubinemia. Choice B is incorrect as lotions can interfere with the effectiveness of phototherapy. Choice D is incorrect as a rash is a common side effect of phototherapy and should not lead to discontinuation unless severe.
What is the recommended method of screening for syphilis during pregnancy?
- A. Venereal disease research laboratory (VDRL) test
- B. Rapid plasma reagin (RPR) test
- C. Fluorescent treponemal antibody absorption (FTA-ABS) test
- D. All of the above
Correct Answer: D
Rationale: Screening for syphilis during pregnancy can involve the VDRL, RPR, or FTA-ABS tests.
Which of the following tests is used to assess fetal lung maturity?
- A. Non-stress test
- B. Biophysical profile
- C. Amniocentesis
- D. Lecithin-sphingomyelin (L/S) ratio
Correct Answer: D
Rationale: The correct answer is D: Lecithin-sphingomyelin (L/S) ratio. This test is used to assess fetal lung maturity by measuring the ratio of two substances found in the amniotic fluid. An L/S ratio greater than 2:1 is indicative of mature fetal lungs. This test is crucial in determining if a baby can breathe adequately after birth. The other choices are incorrect because: A) Non-stress test monitors fetal heart rate and movements, B) Biophysical profile assesses fetal well-being, and C) Amniocentesis is a procedure to collect amniotic fluid for genetic testing.
What is the recommended method of administering vitamin K to a newborn who is at risk for bleeding?
- A. Intramuscular injection
- B. Oral administration
- C. Topical application
- D. Subcutaneous injection
Correct Answer: A
Rationale: The correct answer is A: Intramuscular injection. This method ensures rapid and complete absorption, providing immediate protection against bleeding in newborns. Oral administration may be ineffective due to immature gastrointestinal tract. Topical application may not achieve adequate absorption. Subcutaneous injection may lead to variable absorption rates, delaying the onset of vitamin K's protective effects. Thus, intramuscular injection is the most reliable and recommended method for newborns at risk for bleeding.
A nurse is admitting a client to the labor and delivery unit when the client states, 'My water just broke.' Which of the following interventions is the nurse's priority?
- A. Perform Nitrazine testing.
- B. Assess the fluid.
- C. Check cervical dilation.
- D. Begin FHR monitoring.
Correct Answer: D
Rationale: The correct answer is D: Begin FHR monitoring. This is the priority because it assesses the well-being of the fetus immediately after the client's water breaks, ensuring timely detection of any fetal distress. Performing Nitrazine testing (A) or checking cervical dilation (C) can wait until after FHR monitoring. Assessing the fluid (B) may be important but not as urgent as monitoring the FHR.