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Newborn, preventing heat loss
To prevent heat loss from convection in a newborn, which action by the nurse is best?
- A. Dry the baby after a bath.
- B. Wrap the baby in warmed blankets.
- C. Place the baby in a warmer.
- D. Move infant away from blowing fan.
Correct Answer: D
Rationale: Moving the infant away from a blowing fan directly prevents heat loss due to air movement, which is a key factor in convection.
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Client at 40 weeks gestation, in labor, electronic fetal heart rate monitor tracing
A nurse is observing the electronic fetal heart rate monitor tracing for a client who is at 40 weeks of gestation and is in labor. The nurse should suspect a problem with the umbilical cord when she observes which of the following patterns?
- A. Accelerations.
- B. Late decelerations.
- C. Variable decelerations.
- D. Early decelerations.
Correct Answer: C
Rationale: Variable decelerations indicate fetal hypoxia due to umbilical cord compression, requiring urgent intervention as they suggest the cord is trapped or twisted, impairing fetal oxygen supply.
Client 2 hours postpartum, vaginal birth
A nurse is caring for a client who is 2 hours postpartum following a vaginal birth. Which of the following findings indicates the client's bladder is distended?
- A. Client report of frequent uterine contractions.
- B. Fundus palpable to right of midline.
- C. Less than 2.5 cm of rubra lochia on perineal pad.
- D. Client report of increased thirst.
Correct Answer: B
Rationale: A fundus palpable to the right of midline suggests a distended bladder, which can displace the uterus from its normal position.
Client receiving opioid epidural analgesia during labor
A nurse is caring for a client who is receiving opioid epidural analgesia during labor. Which of the following findings is the nurse's priority?
- A. Blood pressure 80/56 mm Hg.
- B. The client reports profuse itching.
- C. The client reports weakness of the lower extremities.
- D. Temperature 38.2°C (100.8 F).
Correct Answer: A
Rationale: Hypotension (80/56 mm Hg) is the priority as it can reduce placental blood flow, risking fetal distress, and requires immediate intervention.
Infant with axillary temperature of 35.9C (96.6F)
An infant's axillary temperature is 35.9C (96.6F). The priority nursing action is to:
- A. chart the normal axillary temperature.
- B. recheck the infant's temperature rectally.
- C. place the infant in a radiant warmer.
- D. have the mother breastfeed the infant.
Correct Answer: C
Rationale: The low temperature indicates hypothermia, and placing the infant in a radiant warmer is the priority to stabilize body temperature and prevent complications.
Woman gave birth vaginally to a 9-pound, 12-ounce girl yesterday, orders for perineal ice packs, sitz bath, stool softener
A woman gave birth vaginally to a 9-pound, 12-ounce girl yesterday. Her primary health care provider has written orders for perineal ice packs, use of a sitz bath tid, and a stool softener. What information is most closely correlated with these orders?
- A. The woman had a vacuum-assisted birth.
- B. The woman is a gravida 2, para 2.
- C. The woman has an episiotomy.
- D. The woman received epidural anesthesia.
Correct Answer: C
Rationale: An episiotomy correlates with orders for ice packs, sitz baths, and stool softeners, as these address pain and healing of the perineal incision.