Nokea
Which of the following findings should prompt the nurse to reassess the client?
- A. Intense contractions lasting 45 to 60 seconds.
- B. Progressive sacral discomfort during contractions.
- C. A sense of excitement and warm, flushed skin.
- D. An urge to have a bowel movement during contractions.
Correct Answer: D
Rationale: An urge to have a bowel movement during contractions may indicate the baby's head is descending, signaling the need to push. This requires reassessment to check dilation. Intense contractions, sacral discomfort, and excitement with flushed skin are normal labor findings.
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Using Nägele's Rule, which of the following is the client's estimated date of delivery?
- A. May 20.
- B. May 3.
- C. May 13.
- D. May 17.
Correct Answer: D
Rationale: Using Nägele's Rule, subtract 3 months from August 10 (May 10) and add 7 days, resulting in May 17. Other dates result from incorrect day additions.
Which of the following findings places the client at risk for postpartum haemorrhage?
- A. Newborn weight 2.948 kg (6 lb 8 oz).
- B. History of uterine atony.
- C. Labor induction with oxytocin.
- D. History of human papillomavirus.
- E. Vacuum-assisted delivery.
Correct Answer: B,C,E
Rationale: History of uterine atony, oxytocin induction, and vacuum-assisted delivery increase postpartum hemorrhage risk due to impaired uterine contraction, hyperstimulation, or trauma. Newborn weight and HPV are unrelated.
The nurse should monitor for which of the following findings as a manifestation of hypoglycemia?
- A. Abdominal distention.
- B. Petechiae.
- C. Increased muscle tone.
- D. Jitteriness.
Correct Answer: D
Rationale: Jitteriness is a common sign of hypoglycemia in newborns due to low glucose affecting neurological function. Abdominal distention, petechiae, and increased muscle tone are not typical hypoglycemia symptoms.
Which of the following statements should the nurse make to the client?
- A. Swaddle your baby tightly with his legs extended before laying him down to sleep.
- B. Notify your baby's pediatrician if he urinates less than six times a day.
- C. Retract the foreskin to clean your baby's penis during each bath.
- D. Place triple antibiotic ointment on your baby's umbilical cord twice per day.
Correct Answer: B
Rationale: Notifying the pediatrician for fewer than six wet diapers daily ensures adequate hydration monitoring. Extended leg swaddling risks hip dysplasia, foreskin retraction is harmful, and antibiotic ointment is unnecessary for the cord.
Which of the following actions should the nurse take?
- A. Perform vibroacoustic stimulation.
- B. Place the client in the Trendelenburg position.
- C. Conduct a vaginal exam.
- D. Collect a specimen for an indirect Coombs' test.
Correct Answer: A
Rationale: Vibroacoustic stimulation is appropriate to stimulate fetal heart rate accelerations during a nonstress test if none are observed, as it may elicit a response indicating fetal well-being. Trendelenburg position, vaginal exams, or Coombs' tests are not indicated for a nonreactive nonstress test.