Nokea
What teaching is most important for a mother with a newborn receiving phototherapy?
- A. Ensure the newborn wears protective eyewear
- B. Increase the newborn's fluid intake
- C. Turn the newborn frequently to prevent pressure sores
- D. Monitor bilirubin levels every 8 hours
Correct Answer: A
Rationale: Protective eyewear prevents retinal damage during phototherapy.
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The nurse is educating a client about preterm labor. What symptom should the client report immediately?
- A. Frequent urination.
- B. Lower back pain and cramping.
- C. Increased appetite.
- D. Braxton Hicks contractions.
Correct Answer: B
Rationale: Lower back pain and cramping may indicate preterm labor and should be reported promptly.
What is the recommended response for a pregnant client reporting decreased fetal movements?
- A. Encourage the client to lie on her left side
- B. Schedule an immediate ultrasound
- C. Advise monitoring for fetal heart rate decelerations
- D. Instruct the client to monitor movements over the next 48 hours
Correct Answer: C
Rationale: Encouraging the client to monitor fetal movements can help identify any abnormalities early.
The patient came for an induction and under which circumstances does the nurse remove prostaglandin from the patient's cervix? SATA
- A. N&V
- B. Late deceleration
- C. Contractions every 90 seconds
- D. Contractions every 5 minutes
Correct Answer: B
Rationale: A. Nausea and vomiting (N&V) are not typically indications for removing prostaglandin from the patient's cervix during induction. These symptoms are common side effects and can be managed without removing the prostaglandin.
A nurse is caring for a client who is in the first stage of labor, undergoing external fetal monitoring, and receiving IV fluid. The nurse observes variable decelerations in the fetal heart rate on the monitor strip. Which of the following is a correct interpretation of this finding?
- A. Variable decelerations are due to umbilical cord compression.
- B. Variable decelerations are caused by uteroplacental insufficiency.
- C. Variable decelerations are a result of the administration of IV narcotic analgesics.
- D. Variable decelerations are related to fetal head compression.
Correct Answer: A
Rationale: Variable decelerations in the fetal heart rate are due to umbilical cord compression. These decelerations are characterized by an abrupt decrease in the fetal heart rate that is variable in duration, depth, and timing in relation to the uterine contraction. They can signify compression of the umbilical cord leading to transient interruption of fetal oxygen supply. It is essential for the nurse to promptly identify variable decelerations and take appropriate actions to alleviate the compression, such as repositioning the client to relieve pressure on the cord.
Which finding in a 36-week pregnant client is most concerning?
- A. Braxton Hicks contractions
- B. Frequent urination
- C. Proteinuria of +2
- D. Weight gain of 2 pounds in a week
Correct Answer: C
Rationale: Proteinuria is a sign of preeclampsia, requiring immediate assessment.