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When educating a pregnant client about potential complications, which manifestation should the nurse emphasize reporting to the provider promptly?
- A. Vaginal bleeding
- B. Swelling of the ankles
- C. Heartburn after eating
- D. Lightheadedness when lying on back
Correct Answer: A
Rationale: The correct answer is A: Vaginal bleeding. This is crucial to report promptly as it could indicate serious issues like placental abruption or miscarriage. Swelling of the ankles (B) is common in pregnancy but not typically an urgent concern. Heartburn (C) is common and can be managed with lifestyle changes. Lightheadedness when lying on the back (D) is likely due to inferior vena cava compression and can be relieved by changing position. Reporting vaginal bleeding is vital for timely intervention in pregnancy complications.
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A parent is receiving discharge teaching from a nurse regarding caring for their newborn after a circumcision. Which instruction should the nurse include?
- A. Apply slight pressure with a sterile gauze pad for mild bleeding.
- B. Inspect the circumcision site every 6 to 8 hours.
- C. Avoid using baby wipes containing alcohol to cleanse the penis with each diaper change.
- D. Clean the circumcision site daily using a warm, wet washcloth.
Correct Answer: A
Rationale: The correct answer is A: Apply slight pressure with a sterile gauze pad for mild bleeding. This instruction is crucial because it addresses the immediate post-circumcision care to control bleeding. Applying slight pressure with a sterile gauze pad helps to promote clotting and prevent excessive bleeding. This step is essential to ensure the newborn's safety and prevent complications.
Summary of other choices:
B: Inspecting the circumcision site every 6 to 8 hours is important, but not as critical as addressing bleeding promptly.
C: Avoiding baby wipes containing alcohol is a good practice to prevent irritation, but it is not the most urgent instruction for immediate care.
D: Cleaning the circumcision site daily using a warm, wet washcloth is generally recommended for routine care, but in the immediate post-circumcision period, controlling bleeding takes precedence.
A client is in labor, and a nurse observes late decelerations on the electronic fetal monitor. What should the nurse identify as the first action that the registered nurse should take?
- A. Assist the client into the left-lateral position
- B. Apply a fetal scalp electrode
- C. Insert an IV catheter
- D. Perform a vaginal exam
Correct Answer: A
Rationale: The correct answer is A: Assist the client into the left-lateral position. This is the first action because it helps improve placental perfusion, which can alleviate late decelerations associated with uteroplacental insufficiency. The left-lateral position promotes optimal blood flow and oxygenation to the placenta by reducing pressure on the vena cava and improving maternal perfusion. This position can potentially prevent further fetal distress.
Summary of other choices:
B: Applying a fetal scalp electrode is not the first action for addressing late decelerations. It may be considered later for more precise monitoring.
C: Inserting an IV catheter is important but not the priority when late decelerations are observed.
D: Performing a vaginal exam is not indicated as the first action for addressing late decelerations and could potentially increase the risk of infection.
A healthcare provider in an antepartum clinic is collecting data from a client who has a TORCH infection. Which of the following findings should the healthcare provider expect? (Select all that apply)
- A. Joint pain
- B. Malaise
- C. Rash
- D. Tender lymph nodes
Correct Answer: D
Rationale: The correct answer is D: Tender lymph nodes. In TORCH infections, which include Toxoplasmosis, Other (syphilis), Rubella, Cytomegalovirus, and Herpes simplex virus, tender lymph nodes are a common finding due to the body's immune response to the infection. Joint pain (choice A) is not typically associated with TORCH infections. Malaise (choice B) is a general feeling of discomfort and is not specific to TORCH infections. Rash (choice C) is also not a common finding in TORCH infections, making it an incorrect choice.
A healthcare provider is discussing the differences between true labor and false labor with a group of expectant parents. Which of the following characteristics should the healthcare provider include when discussing true labor?
- A. Contractions become stronger with walking.
- B. Discomfort can be relieved with a back massage.
- C. Contractions become irregular with a change in activity.
- D. Discomfort is felt above the umbilicus.
Correct Answer: A
Rationale: The correct answer is A: Contractions become stronger with walking. This is because true labor is characterized by contractions that consistently increase in intensity and frequency, which is often enhanced by physical activity like walking. Contractions in false labor do not typically intensify with movement. Discomfort in true labor is usually not easily relieved by a back massage (B) and contractions in true labor remain regular even with changes in activity (C). Discomfort in true labor is typically felt in the lower abdomen and back, not above the umbilicus (D).
A client presents with uterine hypotonicity and postpartum hemorrhage. Which action should the nurse prioritize?
- A. Check the client's capillary refill.
- B. Massage the client's fundus.
- C. Insert an indwelling urinary catheter for the client.
- D. Prepare the client for a blood transfusion.
Correct Answer: B
Rationale: Rationale: Massaging the client's fundus helps to stimulate uterine contractions and control postpartum hemorrhage caused by uterine hypotonicity. This action helps prevent further blood loss and promotes uterine tone. Checking capillary refill would not directly address the immediate issue of hemorrhage. Inserting a urinary catheter is not a priority in managing postpartum hemorrhage. Preparing for a blood transfusion may be necessary later, but addressing the uterine hypotonicity and hemorrhage is the priority.