Nokea
What is the priority nursing action for a newborn with a temperature of 35.5°C (95.9°F)?
- A. Place the newborn under a radiant warmer
- B. Administer warm IV fluids
- C. Swaddle the newborn in warm blankets
- D. Provide glucose supplementation
Correct Answer: A
Rationale: Placing the newborn under a radiant warmer helps raise body temperature and prevent complications.
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When the nurse is assisting a person desiring contraception, a history and physical is done. What is an important question the nurse should ask?
- A. What is your education level?
- B. Have you ever been pregnant?
- C. Are you married?
- D. What is your exercise routine?
Correct Answer: B
Rationale: When assisting a person desiring contraception, asking whether they have ever been pregnant is an important question because it helps the healthcare provider assess the individual's past reproductive history, including any pregnancies and potential complications. This information is important in determining the most suitable contraceptive options for the person, taking into account their previous experiences with pregnancy and childbirth. It can also help in evaluating the effectiveness of their past contraceptive methods and guide the selection of appropriate contraceptive counseling and options.
A client in labor receiving an epidural reports feeling lightheaded and nauseous. What is the nurse's priority intervention?
- A. Administer antiemetics as prescribed.
- B. Check maternal blood pressure.
- C. Increase the oxytocin infusion rate.
- D. Encourage the client to lie on her back.
Correct Answer: B
Rationale: Lightheadedness and nausea can be signs of hypotension, a common side effect of epidural anesthesia.
What is the primary nursing concern for a mother receiving magnesium sulfate therapy?
- A. Monitor blood pressure every 4 hours
- B. Monitor deep tendon reflexes hourly
- C. Assess respiratory rate and effort
- D. Prepare for delivery if signs of toxicity appear
Correct Answer: B
Rationale: Monitoring reflexes detects early signs of magnesium toxicity.
The nurse suspects that a client has an early sign of ectopic
- B. Abdominal pain
- C. Vaginal spotting or light bleeding
- D. Pelvic pain
Correct Answer: C
Rationale: Vaginal spotting or light bleeding is one of the early signs of an ectopic pregnancy. Ectopic pregnancy occurs when a fertilized egg implants outside the uterus, most commonly in the fallopian tube. The presence of vaginal spotting or light bleeding may indicate the implantation of the fertilized egg in a location other than the uterus, leading to the suspicion of an ectopic pregnancy. It is essential for the nurse to recognize this early sign and promptly assess the client for further evaluation and intervention to prevent complications such as rupture and severe bleeding that can be life-threatening.
A client at 28 weeks' gestation reports regular uterine contractions. What is the nurse's priority intervention?
- A. Administer tocolytic medication.
- B. Perform a sterile vaginal examination.
- C. Assess fetal heart rate and contraction pattern.
- D. Encourage ambulation to relieve discomfort.
Correct Answer: C
Rationale: Assessing fetal heart rate and contraction patterns is critical to evaluate the risk of preterm labor.