Nokea
When planning care for a laboring client, the nurse identifies the need to withhold solids food while the client is in labored. What is the most important reasons for this nursing intervention?
- A. Nausea occurs from analgesics used during labor
- B. Autonomic nervous system stimulation during labor decrease peristalsis
- C. An increased risk of aspiration can occur if general anesthesia is needed
- D. Gastric emptying time decreases during labor.
Correct Answer: C
Rationale: Aspiration risk (C) is a primary reason for withholding solid foods during labor.
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The nurse is assessing a patient's use of complementary and alternative therapies. Which should the nurse document as an alternative or complementary therapy practice?
- A. Practicing yoga daily
- B. Drinking green tea in the morning
- C. Taking omeprazole (Prilosec) once a day
- D. Using aromatherapy during a relaxing bath
Correct Answer: C
Rationale: Yoga, green tea, and aromatherapy are examples of complementary and alternative therapies.
The father of a 3-day old infant who is breastfeeding calls the postpartum help line to report that his wife is acting strangely. She is irritable, cannot cope with the baby, and frequently cries for no appeared reason. What information is most important for the nurse to provide the father?
- A. Contact the clinic if the behaviors continue for more than two weeks or becomes worse
- B. Tell the father count the newborns number of soiled diapers over the next few days.
- C. A fluctuation in hormones in the early postpartum period can cause mood changes.
- D. Recommend giving supplemental bottle feedings to the baby between breast feeding.
Correct Answer: C
Rationale: Hormonal fluctuations (C) are common causes of mood changes in the early postpartum period.
A client at 39-weeks gestation is admitted to the labor and delivery unit in active labor. The client's cervix is dilated 5 cm, 90% effaced, and the fetus is at 0 station. The client's membranes rupture spontaneously, and the fluid is greenish-brown. What action should the nurse take first?
- A. Assess the fetal heart rate pattern.
- B. Perform a vaginal examination.
- C. Prepare for an emergency cesarean section.
- D. Administer oxygen via face mask.
Correct Answer: A
Rationale: Greenish-brown amniotic fluid indicates meconium-stained fluid, and assessing the fetal heart rate pattern is critical to determine fetal well-being.
An obviously pregnant woman walks into the hospital's emergency department entrance shouting. 'Help me! Help me! My baby is coming! I'm so afraid!' The nurse determines if delivery is indeed imminent, what action is most important for the nurse to take?
- A. Determine the gestational age of fetus
- B. Assess the amount and color of the amniotic fluid
- C. Obtain peripheral IV access and begin administration of IV fluids
- D. Provide clear concise instructions in a calm, deliberate manner
Correct Answer: D
Rationale: Providing clear instructions (D) helps manage the situation calmly and effectively.
When assessing a pregnant woman AT 39-weeks gestation who is admitted to labor and delivery which finding is most important to report to the health care provider?
- A. proteinuria
- B. 130/70 blood pressure
- C. pedal edema
- D. 101.2 oral temperature
Correct Answer: D
Rationale: Fever (D) can indicate infection, which requires prompt evaluation.