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A nurse is planning care for a client who is 1 hr postpartum and has peripartum cardiomyopathy. Which of the following actions should the nurse plan to take?
- A. Obtain a prescription for misoprostol.
- B. Assess blood pressure twice daily.
- C. Restrict daily oral fluid intake.
- D. Administer an IV bolus of lactated Ringer's.
Correct Answer: B
Rationale: The correct answer is B: Assess blood pressure twice daily. Postpartum peripartum cardiomyopathy can lead to heart failure and hypertension. Monitoring blood pressure is crucial to detect any worsening of the condition promptly. Misoprostol is not indicated for this condition. Fluid restriction may be necessary in some cases, but oral fluid intake should not be restricted immediately postpartum. Administering IV bolus of lactated Ringer's is not specific to managing peripartum cardiomyopathy. Regular blood pressure monitoring is essential for early detection and management of complications.
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A nurse is providing teaching to a client who is at 35 weeks of gestation and has a prescription for an amniocentesis. Which of the following client statements indicates an understanding of the teaching?
- A. I should empty my bladder before the procedure.
- B. I will be lying on my side during the procedure.
- C. I will be asleep during the procedure.
- D. I should start fasting 24 hours before the procedure.
Correct Answer: A
Rationale: Correct Answer: A. "I should empty my bladder before the procedure."
Rationale: Emptying the bladder before amniocentesis helps avoid accidental puncture during the procedure. A full bladder can be in the needle's path, increasing the risk of injury. This statement demonstrates the client's understanding of the importance of bladder emptying.
Incorrect Choices:
B: "I will be lying on my side during the procedure." - Incorrect. The client will typically be lying flat on their back during amniocentesis.
C: "I will be asleep during the procedure." - Incorrect. Amniocentesis is usually done with local anesthesia, so the client will be awake.
D: "I should start fasting 24 hours before the procedure." - Incorrect. Fasting is not required for amniocentesis. It is a simple procedure that does not involve general anesthesia or fasting.
A nurse is providing prenatal teaching to a client who practices a vegan diet and is trying to increase intake of vitamin B12. Which of the following foods should the nurse recommend?
- A. Fortified soy milk
- B. Raw carrots
- C. Fresh citrus fruits
- D. Brown rice
Correct Answer: A
Rationale: The correct answer is A: Fortified soy milk. Soy milk is often fortified with vitamin B12, making it a suitable option for a client following a vegan diet. Vitamin B12 is primarily found in animal products, so vegans need to ensure they get an adequate intake from fortified foods or supplements. Raw carrots (B), fresh citrus fruits (C), and brown rice (D) do not contain significant amounts of vitamin B12 and would not be effective in increasing intake. A detailed explanation is crucial in guiding the client to make informed choices for their dietary needs.
A nurse is caring for a client who is in the second stage of labor and is experiencing a shoulder dystocia. The provider instructs the nurse to perform the McRoberts maneuver. Which of the following actions should the nurse take?
- A. Apply pressure to the client's fundus.
- B. Press firmly on the client’s suprapubic area.
- C. Move the client onto their hands and knees.
- D. Assist the client in pulling their knees toward their abdomen.
Correct Answer: D
Rationale: The correct answer is D: Assist the client in pulling their knees toward their abdomen. In shoulder dystocia, the McRoberts maneuver involves hyperflexing the mother's legs against her abdomen. This action helps to widen the pelvic outlet and reduce the angle of the pubic symphysis, facilitating the delivery of the infant's shoulder. Pressing on the fundus (A) does not address the shoulder dystocia issue. Pressing on the suprapubic area (B) may not provide the necessary assistance in this situation. Moving the client onto their hands and knees (C) does not facilitate the specific maneuver required. Therefore, assisting the client in pulling their knees toward their abdomen (D) is the correct action in this scenario.
A nurse is caring for a newborn who has jaundice and a new prescription for phototherapy. Which of the following actions should the nurse take?
- A. Provide the newborn with 15 mL glucose water after each feeding.
- B. Turn the newborn every 4 hr.
- C. Apply hydrating lotion to the newborn’s skin prior to treatment.
- D. Close the newborn's eyes before applying eyepatches.
Correct Answer: D
Rationale: The correct action is D: Close the newborn's eyes before applying eyepatches. This is crucial during phototherapy to protect the eyes from potential damage due to exposure to light. Closing the eyes with eyepatches helps prevent eye irritation and potential harm to the sensitive eye tissues. Providing glucose water (A) is not directly related to phototherapy. Turning the newborn (B) every 4 hours is important for general care but not specific to phototherapy. Applying hydrating lotion (C) is not necessary and may interfere with the effectiveness of the treatment.
A nurse is caring for a client who is receiving oxytocin via continuous IV infusion and is experiencing persistent late decelerations in the FHR. After discontinuing the infusion, which of the following actions should the nurse take?
- A. Instruct the client to bear down and push with contractions.
- B. Administer oxygen at 10 L/min via nonrebreather facemask.
- C. Place the client in a supine position.
- D. Initiate an amnioinfusion.
Correct Answer: B
Rationale: The correct answer is B: Administer oxygen at 10 L/min via nonrebreather facemask. Late decelerations in fetal heart rate (FHR) indicate uteroplacental insufficiency, possibly due to decreased oxygen supply to the fetus. Providing oxygen to the mother increases oxygen delivery to the fetus, improving oxygenation and potentially reversing the late decelerations. Other choices are incorrect: A could increase intra-abdominal pressure, worsening late decelerations. C can decrease placental perfusion. D is not indicated for late decelerations.