Nokea
Which item should the client include in her hospital bag?
- A. Comfortable loose clothing
- B. High-heeled shoes
- C. Heavy perfumes
- D. Large meals
Correct Answer: A
Rationale: Comfortable loose clothing is practical for labor and postpartum, ensuring ease and comfort.
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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 nurse advises the client to keep the newborn's crib free of which item?
- A. Soft toys and blankets
- B. Firm mattress
- C. Fitted sheet
- D. Crib bumpers
Correct Answer: A
Rationale: Soft toys and blankets in the crib increase the risk of suffocation and SIDS, and should be avoided.
Using Naegele's Rule, the nurse can assume the client's expected delivery date to be approximately which date?
- A. 13-Nov
- B. 23-Nov
- C. 3-Dec
- D. 20-Dec
Correct Answer: C
Rationale: Naegele's Rule: Subtract 3 months from the first day of the last menstrual period (March 13) and add 7 days, resulting in December 3.
The laboring client suddenly experiences a dramatic drop in the FHR from the 150s to the 110s. A vaginal exam reveals the presence of the fetal cord protruding through the cervix. What should be the nurse’s first intervention?
- A. Put continuous pressure on the presenting part to keep it off the cord
- B. Place the bed in Trendelenburg position
- C. Insert a urinary catheter and instill saline
- D. Continue to monitor the FHR
Correct Answer: A
Rationale: The nurse should first exert continuous pressure on the presenting part to prevent further cord compression. This is continued until birth, which is usually by cesarean section. The bed should be placed in Trendelenburg position to further prevent pressure on the cord, but only after pressure is placed on the presenting part. A catheter may be inserted and 500 mL of warmed saline instilled to help float the head and prevent further compression, but only after pressure is placed on the presenting part. The fetus is continually monitored throughout until birth.
When teaching the class about varicose veins, which symptom should the nurse instruct clients to report immediately?
- A. The appearance of additional varicose veins
- B. Varicose veins that are purple in color
- C. Legs that begin to ache and feel heavy
- D. Calves that become red, tender, and warm
Correct Answer: D
Rationale: Red, tender, warm calves may indicate deep vein thrombosis, a serious condition requiring immediate reporting.