Nokea
Which of the following is a potential complication of a cesarean delivery?
- A. Hemorrhage
- B. Infection
- C. Uterine rupture
- D. All of the above
Correct Answer: D
Rationale: The correct answer is D: All of the above. A cesarean delivery can lead to hemorrhage due to the incision and removal of the placenta. Infection can occur at the incision site or in the uterus post-surgery. Uterine rupture is a rare but serious complication where the uterus tears open. Choosing D is correct as all these complications can potentially arise after a cesarean delivery. Options A, B, and C are incorrect as they do not encompass all possible complications of a cesarean delivery.
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A nurse is admitting a client to the labor and delivery unit when the client states, 'My water just broke.' Which of the following interventions is the nurse's priority?
- A. Perform Nitrazine testing.
- B. Assess the fluid.
- C. Check cervical dilation.
- D. Begin FHR monitoring.
Correct Answer: D
Rationale: The correct answer is D: Begin FHR monitoring. This is the priority because it assesses the well-being of the fetus immediately after the client's water breaks, ensuring timely detection of any fetal distress. Performing Nitrazine testing (A) or checking cervical dilation (C) can wait until after FHR monitoring. Assessing the fluid (B) may be important but not as urgent as monitoring the FHR.
A nurse is assessing the newborn of a client who took a selective serotonin reuptake inhibitor (SSRI) during pregnancy. Which of the following manifestations should the nurse identify as an indication of withdrawal from an SSRI?
- A. Large for gestational age
- B. Hyperglycemia
- C. Bradypnea
- D. Vomiting
Correct Answer: C, D
Rationale: The correct manifestations of SSRI withdrawal in a newborn are bradypnea (C) and vomiting (D). SSRI use during pregnancy can lead to neonatal withdrawal symptoms due to drug exposure in utero. Bradypnea is a common withdrawal symptom characterized by slow breathing rate in newborns. Vomiting is another withdrawal symptom that can occur in newborns exposed to SSRIs. Large for gestational age (A) and hyperglycemia (B) are not typical manifestations of SSRI withdrawal. Therefore, the nurse should focus on monitoring for bradypnea and vomiting as signs of SSRI withdrawal in the newborn.
A nurse is performing a routine assessment on a client who is at 18 weeks of gestation. Which of the following findings should the nurse expect?
- A. Deep tendon reflexes 4+.
- B. Fundal height 14 cm.
- C. Blood pressure 142/94 mm Hg.
- D. FHR 152/min.
Correct Answer: D
Rationale: A fetal heart rate (FHR) of 152/min is within the normal range of 110 to 160 beats per minute for a fetus at 18 weeks of gestation.
A nurse is caring for a client who is to receive oxytocin to augment their labor. Which of the following findings contraindicates the initiation of the oxytocin infusion and should be reported to the provider?
- A. Late decelerations.
- B. Moderate variability of the FHR.
- C. Cessation of uterine dilation.
- D. Prolonged active phase of labor.
Correct Answer: A
Rationale: Late decelerations in the fetal heart rate are a sign of fetal distress and contraindicate the use of oxytocin, as it can exacerbate the distress.
Click to specify which of the following actions the nurse should anticipate including in the client's plan of care. Select all that apply.
- A. Monitor blood pressure.
- B. Initiate contact precautions.
- C. Prepare for amniocentesis .
- D. Apply internal fecal monitor.
- E. Decrease lighting in the client's room
- F. Check urinary output.
- G. Encourage bed rest.
Correct Answer: A,C,G
Rationale: Reposition the client (Trendelenburg or knee-chest)