Nokea
Which intervention is most critical for a mother with a uterine atony postpartum?
- A. Perform uterine massage
- B. Administer oxytocin infusion
- C. Monitor blood pressure and pulse frequently
- D. Encourage breastfeeding to stimulate uterine contractions
Correct Answer: A
Rationale: Performing uterine massage helps contract the uterus and reduce bleeding in uterine atony.
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The nurse assigned to the care of newborn infants understands the importance of keeping these infants swaddled in a warm blanket to prevent heat loss. Why is this important in the care of the newborn?
- A. Chilling leads to increased heat production and greater oxygen needs.
- B. The newborn's metabolic rate is decreased.
- C. Evaporation will affect the newborn's ability to feed.
- D. The newborn will sleep more comfortably.
Correct Answer: A
Rationale: Swaddling newborn infants in a warm blanket is important to prevent heat loss (hypothermia) because when babies become chilled, they must produce more heat to maintain a normal body temperature. This increased heat production leads to higher oxygen needs, which can be detrimental to newborns who may already have limited reserves. Therefore, keeping newborn infants swaddled in a warm blanket helps to maintain their body temperature within a normal range and prevents unnecessary stress on their bodies.
The nurse is preparing a client for induction of labor. What is the primary purpose of administering oxytocin?
- A. Enhance cervical dilation.
- B. Increase maternal blood pressure.
- C. Strengthen uterine contractions.
- D. Prevent postpartum hemorrhage.
Correct Answer: C
Rationale: Oxytocin is used to stimulate uterine contractions to induce or augment labor.
A nurse is caring for a client who is in active labor with 7 cm of cervical dilation and 100% effacement. The fetus is at 1+ station, and the client's amniotic membranes are intact. The client suddenly states that she needs to push. Which of the following actions should the nurse
- A. Assist the client into a comfortable position.
- B. Observe the perineum for signs of crowning.
- C. Have the client pant during the next contractions.
- D. Help the client to the bathroom to void.
Correct Answer: B
Rationale: The sudden urge to push along with the advanced cervical dilation, effacement, and station indicates that the client is likely in the second stage of labor, which is the stage of active pushing. When a woman feels the urge to push, it is essential to assess for the crowning of the fetal head at the perineum as this indicates that the baby is descending and will soon be born. This assessment helps the nurse determine the appropriate actions to take next in assisting the delivery process. Waiting for signs of crowning before guiding the client to push can prevent potential complications related to a rapid birth and help facilitate a more controlled delivery process.
The nurse is caring for a client who just had a cesarean delivery. What is the priority nursing action?
- A. Assess the surgical site.
- B. Monitor for signs of infection.
- C. Assess the uterine fundus for firmness.
- D. Encourage early ambulation.
Correct Answer: C
Rationale: Assessing fundal firmness helps detect uterine atony and prevent postpartum hemorrhage after delivery.
Which client would be at greatest risk for developing
- A. Thick breast cancer?
- B. Wet/slippery with egg white consistency
- C. Client who had her first baby at the age of 24
- D. Client who did not breastfeed
Correct Answer: D
Rationale: Not breastfeeding has been identified as a risk factor for developing breast cancer. Breastfeeding has been shown to have a protective effect against breast cancer due to its impact on hormonal levels and breast tissue changes that occur during lactation. Therefore, compared to other options, the client who did not breastfeed would be at greater risk for developing breast cancer.