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A multiparous client has been in labor for 8 hours when her
membranes rupture. Which action should the nurse
implement first?
Prepare the client for imminent birth.
Assess the fetal heart rate and pattern.
Document the characteristics of the fluid.
Notify the client's primary healthcare provider. - Correct
Answers ✅Assess the fetal heart rate and pattern.
A primigravida at 37 weeks gestation tells the nurse that her
"bag of water" has broken. While inspecting the client's
perineum, the nurse notes the umbilical cord protruding from
the vagina. Which action should the nurse implement first?
Administer 10 L of oxygen via face mask.
Give the healthcare provider a status report.
Place the client in the knee-chest position.
Wrap the cord with gauze soaked in saline. - Correct
Answers ✅Place the client in the knee-chest position.
The nurse observes a new mother avoiding eye contact with
her newborn. Which action should the nurse take?
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Ask the mother why she won't look at the infant.
Observe the mother for other bonding behaviors.
Examine the newborn's eyes for the ability to focus.
Recognize this as a common reaction in new mothers. -
Correct Answers ✅Observe the mother for other bonding
behaviors.
A client states, "During the three months I've been pregnant,
it seems like I have had to go to the bathroom every five
minutes." Which explanation should the nurse provide to this
client?
The client may have a bladder or kidney infection.
Bladder capacity increases during pregnancy.
During pregnancy, a woman is especially sensitive to body
functions.
The growing uterus is putting pressure on the bladder. -
Correct Answers ✅The growing uterus is putting pressure
on the bladder.
Which nursing action should be implemented when
intermittently gavage-feeding a preterm infant?
Allow the formula to flow by gravity.
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Avoid letting the infant suck on the tube.
Insert feeding tube through nares.
Apply steady pressure to the syringe. - Correct Answers
✅Allow the formula to flow by gravity.
A client in her second trimester of pregnancy asks if it is safe
for her to have a drink with dinner. How should the nurse
respond to the client?
During the second trimester beer can be consumed without
harm to the fetus.
Wine can be consumed several times a week after the first
trimester.
Only one drink with the evening meal is not harmful to the
fetus.
Abstinence is strongly recommended throughout the
pregnancy. - Correct Answers ✅Abstinence is strongly
recommended throughout the pregnancy.
The nurse is teaching a new mother about diet and
breastfeeding. Which instruction is most important to include
in the teaching plan?
Avoid alcohol because it is excreted in breast milk.
Avoid spicy foods to prevent infant colic.
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Increase caloric intake by approximately 500 calories/day.
Double prenatal milk intake to improve Vitamin D transfer to
the - Correct Answers ✅Avoid alcohol because it is
excreted in breast milk.
A preterm infant with an apnea monitor experiences an
episode of apnea. Which action should the nurse implement
first?
Ventilate with an Ambu bag.
Perform nasal and airway suctioning.
Administer supplemental oxygen.
Gently rub the infant's feet or back to stimulate respirations
and place in the radiant warmer. - Correct Answers
✅Gently rub the infant's feet or back to stimulate
respirations and place in the radiant warmer.
A client delivers twins, one is stillborn and the other is
recovering in an intensive care nursery. As the nurse provides
assistance to the bathroom, the client, softly crying, states, "I
wish my baby could have lived." Which response is best for
the nurse to provide?
"Don't be sad. You'll need to be strong to care for your
healthy baby."