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 order should the nurse implement first?
- A. Give 1L LR IV (VS indicate hypovolemia from dehydration,
- B. LR will reestablish vascular volume and bring BP up)
- C. Weigh the client
- D. Administer Maalox orally
Correct Answer: A
Rationale: The correct order of implementation in this scenario should focus on addressing the immediate physiological needs of the patient. The vital signs indicating hypovolemia from dehydration require prompt action to stabilize the patient's condition. Giving 1L of LR IV will help reestablish vascular volume, improve blood pressure, and address the underlying issue of dehydration. By addressing the hypovolemia first, the nurse can effectively start the process of stabilizing the patient before moving on to other interventions such as weighing the client, administering Maalox orally, or encouraging liquid intake.
The nurse is educating a pregnant client about group B streptococcus (GBS) testing. When is this typically performed?
- A. At the first prenatal visit.
- B. Between 35–37 weeks' gestation.
- C. During the second trimester.
- D. After 40 weeks' gestation.
Correct Answer: B
Rationale: GBS testing is typically performed between 35–37 weeks to identify and manage infection risks during delivery.
The nurse is educating a client about postpartum care. What statement indicates the need for further teaching?
- A. I will call my doctor if I have a fever.
- B. It is normal to have heavy bleeding for two weeks.
- C. I will avoid lifting heavy objects.
- D. Breast tenderness is common when my milk comes in.
Correct Answer: B
Rationale: Heavy bleeding for two weeks is not normal and may indicate postpartum complications.
The nurse is caring for a client in labor with an epidural. What assessment is most important immediately after placement?
- A. Monitor maternal temperature.
- B. Assess for lower extremity weakness.
- C. Monitor maternal blood pressure.
- D. Check fetal presentation.
Correct Answer: C
Rationale: Maternal blood pressure monitoring is essential to detect and manage hypotension caused by epidural anesthesia.
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.