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A nurse is assisting in the care of a client who is 3 hours postpartum and reports complete saturation of their perineal pad in the past 30 minutes.
Which of the following actions is the highest priority?
- A. Perform fundal massage
- B. Weigh the perineal pad
- C. Apply oxygen by face mask
- D. Monitor urine output
Correct Answer: A
Rationale: Complete saturation of the perineal pad within 30 minutes postpartum suggests excessive bleeding, potentially indicating postpartum hemorrhage. Fundal massage stimulates uterine contractions to control bleeding by compressing blood vessels at the placental site, making it the highest priority action.
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A nurse is checking the reflexes of a newborn.
Which of the following actions should the nurse use to elicit the Babinski reflex?
- A. Touch the corner of the newborn's mouth.
- B. Place the newborn supine and apply pressure to the soles of the feet.
- C. Stroke upward on the lateral aspect of the sole of the newborn's foot
- D. Pull the newborn up by the wrist from a supine position.
Correct Answer: C
Rationale: Stroking upward on the lateral sole elicits the Babinski reflex, where toes fan and extend, a normal newborn response indicating neurological health.
A nurse is reviewing the facility protocol about newborn identification and safety with a new parent. Which of the following information should the nurse include?
- A. You should check the identity of individuals who come to remove your baby from the room
- B. We will scan your baby's identification bracelet each time check on him
- C. We will match the bracelet on your baby with his footprint record each shift
- D. Your baby will wear an electronic bracelet when he is out of your room
Correct Answer: A
Rationale: It's crucial for parents to verify the identity of anyone who comes to take their baby out of the room. This helps ensure the baby's safety and prevents unauthorized individuals from taking the baby. Hospital staff usually wear identification badges, and parents should be encouraged to ask for and verify this identification.
A nurse is assisting with the care of a client who is in labor and has an epidural infusion for pain management. The client's blood pressure is 80/40 mm Hg.
Which of the following actions should the nurse take?
- A. Assist the client to empty her bladder.
- B. Place the client in knee chest position
- C. Administer methylergonovine IM
- D. Give a bolus of lactated Ringer's
Correct Answer: D
Rationale: The client's blood pressure is low (80/40 mm Hg), indicating hypotension, a common side effect of epidural anesthesia during labor. Administering a bolus of intravenous fluids, such as lactated Ringer's solution, is the initial intervention to increase intravascular volume, improving blood pressure and perfusion to vital organs.
A nurse is caring for a client who inquires about available methods of contraception. Which of the following actions should the nurse take?
- A. Perform unbiased teaching
- B. Assess the client's socioeconomic status
- C. Collect a dietary history
- D. Select the best method of contraception for the client.
Correct Answer: A
Rationale: The nurse should provide comprehensive and unbiased information about the various methods of contraception available. This involves explaining the pros and cons of each method, effectiveness, potential side effects, and how each method aligns with the client's lifestyle and health needs, allowing the client to make an informed decision.
A nurse in a prenatal clinic is reinforcing teaching with a client who is at 20 weeks of gestation and has a low calcium level.
Which of the following foods should the nurse recommend the client increase in her diet?
- A. Peanut butter
- B. Avocados
- C. Yogurt
- D. Long-grain rice
Correct Answer: C
Rationale: Yogurt is an excellent calcium source, vital for fetal bone development and maternal health, making it the best recommendation for low calcium levels.