Nokea
What is the priority for a newborn presenting with grunting and nasal flaring?
- A. Administer oxygen at 2 L/min via nasal cannula
- B. Start IV fluids to maintain hydration
- C. Position the newborn in a semi-Fowler's position
- D. Administer antibiotics to prevent infection
Correct Answer: A
Rationale: Administering oxygen helps improve oxygenation for a newborn in respiratory distress.
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A nurse is caring for a client who is 4 hr postpartum following a vaginal birth. The client has saturated a perineal pad within 10 min. Which of the following actions should the nurse take first
- A. Assess client's blood pressure.
- B. Assess the bladder for distention.
- C. Massage the client's fundus.
- D. Prepare to administer a prescribed oxytocic preparation.
Correct Answer: B
Rationale: The first action the nurse should take in this situation is to assess the bladder for distention. Postpartum hemorrhage can be caused by a distended bladder putting pressure on the uterus, preventing it from contracting effectively and leading to excessive bleeding. By assessing for bladder distention and ensuring the client empties her bladder, the nurse can help the uterus contract more efficiently and potentially reduce the bleeding. Assessing the other options such as blood pressure, massaging the fundus, and preparing to administer an oxytocic can be important interventions eventually, but addressing the bladder distention is the first priority in this case of excessive postpartum bleeding.
A nurse is caring for a client who has preeclampsia and is being treated with magnesium sulfate IV. The client's respiratory rate is 10/min and deep-tendon reflexes are absent. Which of the following actions should the nurse take?
- A. Discontinue the medication infusion.
- B. Prepare for an emergency cesarean birth.
- C. Assess maternal blood glucose.
- D. Place the client in Trendelenburg position.
Correct Answer: A
Rationale: The most appropriate action for the nurse to take in this situation is to discontinue the medication infusion. The client is showing signs of magnesium sulfate toxicity, which can include respiratory depression (low respiratory rate) and absent deep-tendon reflexes. These are early signs of magnesium toxicity, and prompt action is needed to prevent further complications. Discontinuing the medication infusion will help reduce the risk of magnesium toxicity worsening. The other options are not appropriate in this situation as they do not address the immediate concern of magnesium toxicity.
The nurse is teaching a prenatal class about kick counts. When should the client contact the healthcare provider?
- A. Fewer than 10 movements in 2 hours.
- B. Fewer than 5 movements in 1 hour.
- C. No movements after a meal.
- D. No movements for 6 hours.
Correct Answer: A
Rationale: Fewer than 10 movements in 2 hours is concerning and warrants further evaluation.
Why is it important to consider special considerations, such as age, cultural background, or specific health conditions, during a health history for a well-person exam?
- A. to tailor the examination and screening tests to the individual’s health needs
- B. to assess the risk of occupational and environmental exposures
- C. to determine the individual's immunization history
- D. to identify potential safety considerations, such as intimate partner violence or mental abuse
Correct Answer: A
Rationale:
The nurse is preparing a client for a postpartum tubal ligation. What is the priority preoperative nursing action?
- A. Insert an indwelling catheter.
- B. Verify signed informed consent.
- C. Administer prescribed antibiotics.
- D. Check for maternal vital signs.
Correct Answer: B
Rationale: Verifying informed consent is essential before proceeding with any surgical procedure.