Nokea
While assisting with the care of a client in active labor, a nurse observes clear fluid and a loop of pulsating umbilical cord outside the client's vagina. Which of the following actions should the nurse perform first?
- A. Place the client in the Trendelenburg position
- B. Apply finger pressure to the presenting part
- C. Administer oxygen at 10 L/min via a non-rebreather
- D. Call for assistance
Correct Answer: D
Rationale: The correct answer is D: Call for assistance. This is the first action the nurse should take in this emergency situation. Calling for help ensures that additional support and resources are available to manage the situation effectively. Placing the client in the Trendelenburg position (A) is not recommended as it can worsen the prolapsed cord. Applying finger pressure to the presenting part (B) can lead to further complications. Administering oxygen (C) may be necessary but is not the priority when a prolapsed cord is present.
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A charge nurse on the postpartum unit is observing a newly licensed nurse who is preparing to administer pain medication to a client. The charge nurse should intervene when the newly licensed nurse uses which of the following secondary identifiers to identify the client?
- A. The client's room number
- B. The client's telephone number
- C. The client's birth date
- D. The client's medical record number
Correct Answer: A
Rationale: The correct answer is A: The client's room number. Using the client's room number as a secondary identifier is not appropriate as it does not uniquely identify the client and can lead to errors. The room number may change, or there could be multiple clients in the same room. Telephone number, birth date, and medical record number are more reliable secondary identifiers as they are unique to the client and less likely to be confused with another individual. It is essential to use accurate and reliable identifiers to ensure patient safety and prevent medication errors.
When caring for a client suspected of having hyperemesis gravidarum, which finding is a manifestation of this condition?
- A. Hgb 12.2 g/dL
- B. Urine ketones present
- C. Alanine aminotransferase 20 IU/L
- D. Blood glucose 114 mg/dL
Correct Answer: B
Rationale: The correct answer is B: Urine ketones present. Hyperemesis gravidarum is a severe form of nausea and vomiting during pregnancy, leading to dehydration and ketonuria. Presence of urine ketones indicates fat breakdown due to inadequate calorie intake. Option A is within normal range for hemoglobin. Option C is within normal range for alanine aminotransferase. Option D is within normal range for blood glucose. Thus, the presence of urine ketones is the most indicative finding for hyperemesis gravidarum.
A client is in labor, and a nurse observes late decelerations on the electronic fetal monitor. What should the nurse identify as the first action that the registered nurse should take?
- A. Assist the client into the left-lateral position
- B. Apply a fetal scalp electrode
- C. Insert an IV catheter
- D. Perform a vaginal exam
Correct Answer: A
Rationale: The correct answer is A: Assist the client into the left-lateral position. This is the first action because it helps improve placental perfusion, which can alleviate late decelerations associated with uteroplacental insufficiency. The left-lateral position promotes optimal blood flow and oxygenation to the placenta by reducing pressure on the vena cava and improving maternal perfusion. This position can potentially prevent further fetal distress.
Summary of other choices:
B: Applying a fetal scalp electrode is not the first action for addressing late decelerations. It may be considered later for more precise monitoring.
C: Inserting an IV catheter is important but not the priority when late decelerations are observed.
D: Performing a vaginal exam is not indicated as the first action for addressing late decelerations and could potentially increase the risk of infection.
A healthcare professional is assessing a late preterm newborn. Which of the following clinical manifestations is an indication of hypoglycemia?
- A. Hypertonia
- B. Increased feeding
- C. Hyperthermia
- D. Respiratory distress
Correct Answer: D
Rationale: The correct answer is D: Respiratory distress. Hypoglycemia in a late preterm newborn can lead to respiratory distress due to inadequate energy supply to respiratory muscles. Hypertonia (choice A) may indicate other issues such as hypocalcemia. Increased feeding (choice B) is not a typical clinical manifestation of hypoglycemia, as the newborn may have poor feeding due to low energy levels. Hyperthermia (choice C) is not directly related to hypoglycemia but may occur in response to infection or other causes. Thus, respiratory distress is the most indicative of hypoglycemia in this scenario.
A nurse is preparing to perform Leopold maneuvers for a client. Identify the sequence the nurse should follow.
- A. Palpate the fundus to identify the fetal part.
- B. Determine the location of the fetal back.
- C. Palpate for the fetal part presenting at the inlet.
- D. All of the Above
Correct Answer: D
Rationale: The correct sequence for performing Leopold maneuvers is to first palpate the fundus to identify the fetal part (A), then determine the location of the fetal back (B), and finally palpate for the fetal part presenting at the inlet (C). Choosing option D (All of the Above) is correct because it encompasses all the necessary steps in the correct order to perform Leopold maneuvers effectively. Palpating the fundus helps identify the presenting part, determining the location of the fetal back provides information on the fetal lie, and palpating for the presenting part at the inlet helps confirm the position of the fetus. The other choices are incorrect because they do not provide the complete sequence required for performing Leopold maneuvers accurately.