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A nurse is assisting with the care of a client who has been admitted to the labor and delivery unit.
Which of the following diagnostic results should the nurse address first?
- A. Hematocrit 32% (normal range: 32% to 47%).
- B. Hemoglobin 10 g/dL (normal range: 11 to 16 g/dL).
- C. WBC 20,000/mm³ (normal range: 5,000 to 15,000/mm³).
- D. Maternal blood type O negative.
Correct Answer: C
Rationale: An elevated WBC count of 20,000/mm³ suggests infection or inflammation, a priority during labor requiring immediate attention.
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A nurse is contributing to the plan of care for a newborn who requires phototherapy for hyperbilirubinemia.
Which of the following interventions should the nurse recommend including in the plan?
- A. Reposition the newborn every 2 hours.
- B. Give the newborn 30 ml of distilled water after each feeding.
- C. Monitor the newborn's blood glucose level every hour.
- D. Apply a water-based ointment to the newborn's skin every 6 hours.
Correct Answer: A
Rationale: Repositioning the newborn every 2 hours ensures even exposure to phototherapy light, preventing skin breakdown and effectively reducing bilirubin levels.
A nurse is reinforcing teaching with a client who is pregnant and does not consume dairy products.
Which of the following food options should the nurse recommend as the best source of dietary calcium?
- A. 1 cup sweet white corn.
- B. 1 baked potato.
- C. 1 cup kale.
- D. 1 large banana.
Correct Answer: C
Rationale: Kale is an excellent non-dairy calcium source, providing about 177 mg per cup, ideal for meeting pregnancy calcium needs.
A nurse in a provider's office is collecting data from a client who is at 34 weeks of gestation and reports having a sudden gush of vaginal fluid.
Which of the following manifestations is the priority?
- A. Maternal temperature 38.3°C (101°F).
- B. Fetal heart tones 98/min.
- C. Foul-smelling vaginal discharge.
- D. Amniotic fluid with meconium noted.
Correct Answer: B
Rationale: Fetal heart tones at 98/min are significantly lower than the normal range (110-160/min), indicating fetal distress and requiring immediate intervention.
A nurse is caring for a client who inquires about available methods of contraception.
Which of the following actions should the nurse take?
- A. Collect a dietary history.
- B. Assess the client's socioeconomic status.
- C. Perform unbiased teaching.
- D. Select the best method of contraception for the client.
Correct Answer: C
Rationale: Performing unbiased teaching provides comprehensive contraception information, empowering the client to make an informed decision autonomously.
A nurse is planning to administer Rh(D) immune globulin to a client who is postpartum.
Which of the following actions should the nurse take?
- A. Verify that the newborn is Rh-negative.
- B. Verify that the client's Coombs test is positive.
- C. Administer the medication into the client's abdomen.
- D. Administer the medication within 72 hours after birth.
Correct Answer: D
Rationale: Administering Rh(D) immune globulin within 72 hours prevents Rh sensitization in Rh-negative mothers, crucial for future pregnancies.