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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.
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A nurse is assisting with the care of a newborn who has neonatal abstinence syndrome.
Which of the following actions should the nurse take first?
- A. Swaddle the newborn in blankets.
- B. Weigh the newborn's wet diaper.
- C. Auscultate the newborn's bowel sounds.
- D. Determine the newborn's respiratory rate.
Correct Answer: D
Rationale: Determining the respiratory rate first ensures airway and breathing stability, a critical initial step in managing neonatal abstinence syndrome.
A home health nurse is caring for a client who has unilateral mastitis and is experiencing discomfort in the affected breast.
Which of the following instructions should the nurse include?
- A. Recommend the client avoid wearing a nursing bra until symptoms resolve.
- B. Suggest the client apply warm compresses to the affected breast.
- C. Encourage the client to limit oral fluid intake to decrease milk production.
- D. Tell the client to apply hydrocortisone ointment to the affected area.
Correct Answer: B
Rationale: Applying warm compresses relieves pain and inflammation in mastitis, promoting circulation and healing.
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.
Nurses' Notes: The client, who is 28 weeks gestation, gravida 4, para 3, reports a history of vaginal bleeding for the past 2 hours. She states, 'I started bleeding a couple of hours ago, but now I am saturating pads with bright red blood. I’m scared something is going to happen to my baby.' Blood is trickling down her legs. She denies abdominal pain. A perineal pad is saturated with bright red vaginal bleeding. Physical Examination Results: Fundal height is 27 cm. No uterine contractions or irritability. Fetal heart rate: 170/min, minimal variability, no decelerations. Diagnostic Results: Urine: Leukocyte esterase positive, Nitrites positive, Red blood cells: 6.
Complete the diagram by dragging from the choices below to specify: Potential Condition, Actions to Take (Select 2), Parameters to Monitor (Select 2). Potential Condition Choices: A. Placenta previa, B. Abruptio placentae, C. Preterm labor, D. Uterine rupture. Actions: A. Administer methotrexate, B. Administer broad-spectrum antibiotics, C. Prepare for an emergency cesarean birth, D. Reinforce bed rest and maintain IV access, E. Encourage ambulation. Parameters: A. Fetal heart rate, B. Maternal oxygen saturation, C. WBC count, D. Urine output, E. Uterine contractions.
- A. Placenta previa
- B. Prepare for an emergency cesarean birth
- C. Reinforce bed rest and maintain IV access
- D. Fetal heart rate
- E. Maternal oxygen saturation
Correct Answer: A,C,D,A,B
Rationale: Painless bleeding suggests placenta previa; cesarean and bed rest manage it; fetal heart rate and oxygen saturation monitor stability.
A nurse is caring for a client who is at 9 weeks of gestation and reports nausea in the morning that continues until midafternoon.
Which of the following actions should the nurse encourage the client to take?
- A. Eat dry, bland foods in the morning.
- B. Take an over-the-counter antacid.
- C. Increase intake of fresh fruits.
- D. Restrict fluids to 1,000 ml/day.
Correct Answer: A
Rationale: Eating dry, bland foods like crackers in the morning can alleviate nausea by absorbing stomach acid, a common remedy for early pregnancy nausea.