Upon delivery of the newborn, the nursing intervention that most promotes parental attachment is:
- A. Placing the infant under the radiant warmer
- B. Allowing the mother to rest immediately after delivery
- C. Placing the newborn on mother's chest and abdomen
- D. Taking the newborn to the nursery for the initial assessment
Correct Answer: C
Rationale: Skin-to-skin contact enhances bonding.
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What is the priority action for a newborn with a positive Coombs test?
- A. Begin phototherapy immediately
- B. Monitor for jaundice progression
- C. Administer immunoglobulin therapy
- D. Initiate exchange transfusion procedures
Correct Answer: B
Rationale: Monitoring jaundice progression is crucial for managing hemolytic disease.
What serum laboratory reports would the nurse expect in a bulimic client?
- A. Potassium 3.0 mEq/L.
- B. Bicarbonate 30 mmol/L.
- C. Platelet count 450,000 cells/mm3.
- D. Hemoglobin A1C 9%.
Correct Answer: A
Rationale: Low potassium levels result from vomiting and purging.
A nurse on a labor unit is admitting a client who reports painful contractions. The nurse determines that the contractions have a duration of 1 min and a frequency of 3 min. The nurse obtains the following vital signs: fetal heart rate 130/min, maternal heart rate 128/min and maternal blood pressure 92/54 mm Hg. Which of the following is the priority action for the nurse to take?
- A. Notify the provider of the findings.
- B. Position the client with one hip elevated.
- C. Ask the client if she needs pain medication.
- D. Have the client void.
Correct Answer: A
Rationale: The priority action for the nurse in this situation is to notify the provider of the vital signs and the client's condition. The maternal blood pressure of 92/54 mm Hg is low, which can indicate hypotension. Hypotension during labor can lead to decreased perfusion to both the mother and baby, potentially causing harm. Therefore, the provider needs to be notified promptly so that appropriate interventions can be initiated to address the maternal hypotension and ensure the well-being of both the mother and the baby. Positioning the client with one hip elevated, asking about pain medication, and having the client void can be important interventions, but they are not the priority in this situation where maternal hypotension is a concern.
A nurse is assessing a client following an amniocentesis. Which of the following findings should the nurse recognize as complications? (Select all that apply).
- A. Amnionitis
- B. Urinary tract infection
- C. Polyhydramnios
- D. Leakage of amniotic fluid
Correct Answer: A
Rationale: A. Amnionitis: This is the inflammation of the amniotic sac or membranes and is a potential complication following an amniocentesis procedure. It can lead to maternal fever, fetal tachycardia, and other signs of infection.
What is an example of a nurse's question that is part of the Four Cs?
- A. What did you do to cause your injury?
- B. What are you concerned about today?
- C. What kind of problems will your traditions cause for other patients?
- D. When will your family move you in to stay with them?
Correct Answer: B
Rationale: The Four Cs (Concerns, Causes, Comfort, and Collaboration) focus on understanding the patient's perspective and concerns.