Nokea
What is the priority nursing intervention for a newborn with respiratory distress?
- A. Administer oxygen and position the newborn
- B. Suction the airway and provide stimulation
- C. Start IV antibiotics immediately
- D. Monitor heart rate and blood pressure
Correct Answer: A
Rationale: Administering oxygen and positioning the newborn can improve respiratory function.
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The nurse is caring for a client with suspected placenta previa. What is the priority nursing intervention?
- A. Perform a sterile vaginal examination.
- B. Monitor fetal heart rate and maternal vital signs.
- C. Administer oxytocin to stop the bleeding.
- D. Encourage the client to ambulate.
Correct Answer: B
Rationale: Monitoring maternal and fetal well-being is critical in cases of placenta previa to detect complications.
The nurse is performing an assessment on a client who is at 38 weeks' gestation and notes that the fetal heart rate is 174 beats/minute. What is the priority nursing action?
- A. Document the finding.
- B. Check the mother's heart rate.
- C. Notify the health care provider (HCP).
- D. Tell the client that the fetal heart rate is normal.
Correct Answer: C
Rationale: A fetal heart rate above 160 bpm at term may indicate fetal distress, requiring immediate notification of the HCP.
LGBTQIA+ families are at higher risk for certain issues more than straight, cisgender parents. What is an example of a vulnerability experienced by LGBTQIA+ families?
- A. increased cases of social exclusion
- B. fewer cases of intimate partner violence
- C. fewer incidents of family trauma
- D. increased cases of social acceptance
Correct Answer: A
Rationale: LGBTQIA+ families often face social exclusion and discrimination, increasing their vulnerability to mental and physical health challenges.
The nurse is caring for a client with gestational hypertension. What symptom should be reported immediately?
- A. Headache unrelieved by acetaminophen.
- B. Slight swelling of the hands.
- C. Mild nausea after eating.
- D. Fatigue at the end of the day.
Correct Answer: A
Rationale: Headache unrelieved by medication may indicate worsening gestational hypertension or preeclampsia.
Mother in late middle age who is certain she is not pregnant tells
the nurse during an office visit she has urinary problems as well as
sensation of bearing down and of something in the vagina. The nurse
should realize that the client is most likely suffering from:
- A. Uterine prolapse
- B. Cystocele/rectocele
- C. Urinary tract infection (UTI)
- D. Endometriosis
Correct Answer: B
Rationale: A cystocele/rectocele occurs when the supportive tissue between a woman's bladder and vaginal wall weakens, allowing the bladder to bulge into the vagina. This can lead to urinary problems such as difficulty emptying the bladder completely, frequent urination, and urinary incontinence. The fact that the mother is in late middle age and certain she is not pregnant, combined with her urinary problems, suggests that she may be experiencing symptoms of a cystocele/rectocele. It is important for the nurse to further assess the client's symptoms and provide appropriate education and treatment options.