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When caring for a neonate diagnosed with gastroschisis, which of the following actions should the nurse record to do first?
- A. Weigh the neonate.
- B. Insert an orogastric tube.
- C. Prepare for immediate blood transfusion.
- D. Cover the abdomen with a moistened sterile gauze.
Correct Answer: D
Rationale: Covering the abdomen with moistened sterile gauze prevents infection and dehydration of the exposed intestines, which is the first priority.
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The labor and delivery unit is short-staffed, and the charge nurse must prioritize assignments. Which client should the registered nurse personally assess first?
- A. A primigravida at 4 cm dilation requesting pain relief.
- B. A multigravida at 8 cm dilation with a history of rapid labors.
- C. A primigravida with stable vital signs post-epidural.
- D. A multigravida at 6 cm dilation with a reassuring fetal monitor.
Correct Answer: B
Rationale: A multigravida at 8 cm dilation with a history of rapid labors is at risk for precipitous delivery, requiring immediate RN assessment to prepare for birth. Other clients are less urgent, as they are earlier in labor or stable.
A client is considering the hormonal IUD. Which of the following client statements indicates a need for further teaching?
- A. The IUD may reduce my menstrual bleeding.
- B. The IUD can stay in place for several years.
- C. The IUD will prevent ovulation every month.
- D. The IUD does not protect against STIs.
Correct Answer: C
Rationale: The hormonal IUD does not primarily prevent ovulation every month; it mainly thins the uterine lining and thickens cervical mucus. The other statements are correct, indicating a need for further teaching.
A primiparous client who underwent a cesarean delivery 30 minutes ago is to receive Rho(D) immune globulin (RhoGAM). The nurse should administer the medication within which of the following time frames after delivery?
- A. 8 hours.
- B. 24 hours.
- C. 72 hours.
- D. 96 hours.
Correct Answer: C
Rationale: RhoGAM should be administered within 72 hours postpartum to prevent Rh sensitization.
A primigravid client at 37 weeks' gestation has been hospitalized for several days with severe pregnancy-induced hypertension. While caring for the client, the nurse observes that the client is beginning to have a seizure. Which of the following actions should the nurse do first?
- A. Pad the side rails of the client's bed.
- B. Turn the client to the right side.
- C. Insert a padded tongue blade into the client's mouth.
- D. Call for immediate assistance in the client's room.
Correct Answer: D
Rationale: A seizure in pregnancy-induced hypertension (eclampsia) is a medical emergency. Calling for immediate assistance ensures rapid intervention (e.g., magnesium sulfate). Padding rails, repositioning, or inserting a tongue blade (which is outdated) are secondary.
A laboring client at -2 station has a spontaneous rupture of the membranes and a cord immediately protrudes from the vagina. The nurse should first:
- A. Place gentle pressure upward on the fetal head.
- B. Place the cord back into the vagina to keep it moist.
- C. Begin oxygen by face mask at 8 to 10 L/min.
- D. Turn the client on her left side.
Correct Answer: A
Rationale: Gentle pressure prevents cord compression.