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Which of the following nursing actions should the nurse plan to take? For each potential nursing action, click to specify it the intervention is indicated or contraindicated for the client.
- A. Insert a large bore intravenous catheter.
- B. Assess cervical dilation.
- C. Weigh perineal pads.
- D. Administer methotrexate.
Correct Answer: A, C
Rationale: Inserting a large bore IV catheter is indicated to manage potential hemorrhage. Weighing perineal pads helps quantify blood loss. Assessing cervical dilation is contraindicated as it may exacerbate bleeding. Administering methotrexate is not relevant in this context.
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A nurse is caring for a client who is hypotensive following the administration of epidural anesthesia. Which of the following actions should the nurse take?
- A. Turn the client to a side-lying position.
- B. Apply oxygen at 2 L/min via nasal cannula.
- C. Massage the client’s fundus.
- D. Assist the client to empty their bladder.
Correct Answer: A
Rationale: The correct answer is A: Turn the client to a side-lying position. This helps to improve blood flow and circulation, which can help increase blood pressure in a hypotensive client. Placing the client on their side also helps prevent potential complications such as supine hypotension syndrome.
Choice B is incorrect because administering oxygen may not directly address the underlying cause of hypotension in this situation.
Choice C is incorrect as massaging the fundus is typically done to assess postpartum bleeding in women who have recently given birth, not for hypotension following epidural anesthesia.
Choice D is incorrect because while emptying the bladder can help in some cases of hypotension, it may not be the most immediate or appropriate action in this scenario.
A nurse is caring for a client who is at 10 weeks of gestation. Which of the following findings should the nurse report to the provider?
- A. Frequent vomiting with weight loss of 3 lb in 1 week
- B. Reports of mood swings
- C. Nosebleeds occurring approximately 3 times per week
- D. Increased vaginal discharge
Correct Answer: A
Rationale: Frequent vomiting with significant weight loss may indicate hyperemesis gravidarum, a condition that requires medical intervention to prevent dehydration and nutritional deficiencies.
Which of the following hormones is responsible for stimulating milk production during lactation?
- A. Progesterone
- B. Estrogen
- C. Prolactin
- D. Oxytocin
Correct Answer: C
Rationale: Prolactin is the hormone responsible for stimulating milk production during lactation.
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 teaching about home safety with a client who is 2 days postpartum. Which of the following instructions should the nurse include in the teaching?
- A. Bathe your baby immediately after a feeding.
- B. Place a bumper pad in your baby’s crib.
- C. Put a soft mattress in your baby’s crib.
- D. Wash your baby’s face with plain water.
Correct Answer: D
Rationale: The correct answer is D: Wash your baby’s face with plain water. This instruction is important as newborns have sensitive skin that can easily become irritated by harsh chemicals found in soaps. Washing the baby's face with plain water helps to keep their skin clean without causing any harm.
A: Bathing the baby immediately after a feeding can lead to discomfort and potential regurgitation.
B: Placing a bumper pad in the crib can increase the risk of suffocation or Sudden Infant Death Syndrome (SIDS).
C: Putting a soft mattress in the crib increases the risk of suffocation and poses a potential hazard to the baby's safety.
In summary, choosing option D ensures the safety and well-being of the newborn by providing gentle care for their delicate skin without introducing unnecessary risks or hazards.