Nokea
Which instruction is most appropriate for a client with a history of preterm birth?
- A. Monitor for uterine contractions
- B. Avoid prenatal vitamins
- C. Limit fluid intake
- D. Resume normal activity levels
Correct Answer: A
Rationale: Monitoring for uterine contractions is critical for a client with a history of preterm birth to detect early signs of preterm labor.
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The nurse observes on the monitor tracing of the client in the transition phase of labor that the baseline FHR is 160 and that there is moderate variability with V-shaped decelerations unrelated to contractions. What should the nurse do first?
- A. Prepare for delivery.
- B. Notify the obstetrician.
- C. Apply oxygen nasally.
- D. Reposition the client.
Correct Answer: D
Rationale: Repositioning the client to her side or to knee-chest should be done first to take the pressure off the umbilical cord. Variable decelerations usually result from cord compression and stretching during fetal descent. The fetus has a normal baseline HR and good variability. There is no indication that immediate delivery is necessary. Other measures could correct the V-shaped (variable) decelerations. Other nursing measures are used to correct the V-shaped (variable) decelerations prior to contacting the obstetrician (or midwife). Repositioning the client should be implemented prior to giving her oxygen.
Which statement by the client indicates a need for further psychosocial support?
- A. I feel ready to bond with my baby.
- B. I am excited about becoming a mother.
- C. I feel worthless and overwhelmed daily.
- D. I have a great support system at home.
Correct Answer: C
Rationale: Feeling worthless and overwhelmed daily suggests potential depression, indicating a need for additional psychosocial support.
A 5-minute-old newborn in a delivery room has a good cry, HR 88, well flexed, good reflex irritability, and blue extremities with a completely pink body. What Apgar score would the nurse document for this newborn?
Correct Answer: 8
Rationale: The newborn would receive one point because the HR is below 100 bpm, two points for a good cry (respiratory effort), two points for being well flexed (muscle tone), two points for good reflex irritability (reflex response), and one point for a pink body with blue extremities (color).
The postpartum client tells the nurse that she has pain when she breastfeeds. The nurse identifies that the infant has poor latch during breastfeeding. Which breast appearance shows that the client is experiencing symptoms associated with poor latch?
- A. Normal breasts
- B. Left breast with mastitis
- C. Engorged breasts
- D. Breasts with reddened, cracked nipples
Correct Answer: D
Rationale: This graphic shows normal breasts. This graphic shows the left breast with mastitis. Mastitis frequently presents as redness, warmth, and tenderness of the breast tissue, rather than the nipple. This graphic shows engorged breasts. This graphic shows breasts that have reddened nipples, one of which is cracked. If proper latch is not obtained during breastfeeding, the newborn’s sucking may cause nipple cracking, blistering, and bleeding.
Which dietary recommendation supports postpartum recovery?
- A. High-protein, balanced diet
- B. Low-calorie, restrictive diet
- C. High-sugar snacks
- D. Caffeine-only beverages
Correct Answer: A
Rationale: A high-protein, balanced diet supports tissue repair and energy needs during postpartum recovery.