Nokea
What immediate action should a nurse take for a mother reporting a severe headache postpartum?
- A. Administer analgesics and monitor blood pressure
- B. Encourage the mother to rest
- C. Apply a cold compress to the mother's head
- D. Notify the healthcare provider immediately
Correct Answer: D
Rationale: A severe headache postpartum can indicate preeclampsia or other serious conditions requiring immediate action.
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Which newborn is at highest risk of a skin infection? of the FHR?
- A. Infant born at 36 weeks who is being bottle fed
- B. Right lower abdomen
- C. Infant whose umbilical cord fell off on day 8 of life
- D. Near client umbilicus
Correct Answer: C
Rationale: The newborn infant whose umbilical cord fell off on day 8 of life is at highest risk of a skin infection. This is because the umbilical cord stump is an area prone to bacterial colonization and can lead to infection if proper care is not maintained during the cord care period. Once the umbilical cord falls off, the skin in that area is exposed and vulnerable to infection. It is important to educate parents on proper cord care techniques to prevent infection in this high-risk period.
The nurse is caring for a client at 38 weeks' gestation with suspected placental abruption. What is the priority nursing action?
- A. Assess maternal vital signs and fetal heart rate.
- B. Prepare the client for immediate cesarean delivery.
- C. Administer oxygen at 2 L/min via nasal cannula.
- D. Insert an indwelling urinary catheter.
Correct Answer: A
Rationale: Assessing maternal and fetal status is the first step to determine the urgency and appropriate intervention.
What is the theory that supports HypnoBirthing?
- A. the fear-tension-pain theory
- B. the theory that pain is productive in labor
- C. the idea that self-hypnosis always works if you try hard enough
- D. the theory that when hypnotized during labor, the environment does not matter because the person is not aware of the surroundings
Correct Answer: A
Rationale: HypnoBirthing is based on the fear-tension-pain theory, which links fear to increased tension and pain.
A nurse is caring for a client who is to undergo an amniotomy. Which of the following is the priority nursing action following this procedure?
- A. Observe color and consistency of fluid.
- B. Assess the fetal heart rate pattern.
- C. Assess the client's temperature.
- D. Evaluate client for the presence of chills and increased uterine tenderness using palpation.
Correct Answer: B
Rationale: The priority nursing action following an amniotomy (rupture of the amniotic sac) is to assess the fetal heart rate pattern. This is crucial to monitor for any signs of fetal distress or complications that may arise after the procedure. Changes in the fetal heart rate pattern can indicate the need for interventions to ensure the well-being of the fetus. Observing the color and consistency of the amniotic fluid, assessing the client's temperature, and evaluating for the presence of chills and increased uterine tenderness are also important assessments following amniotomy, but assessing the fetal heart rate takes precedence in this situation to ensure the safety of the fetus.
A client at 32 weeks' gestation reports regular uterine contractions every 10 minutes. What is the nurse's priority action?
- A. Administer tocolytic medication as prescribed.
- B. Perform a sterile vaginal examination.
- C. Assess for cervical changes and fetal heart rate.
- D. Encourage ambulation to relieve discomfort.
Correct Answer: C
Rationale: Assessing cervical changes and fetal heart rate is essential to determine whether the client is in preterm labor.