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A pregnant client at 30 weeks gestation reports severe headache, visual disturbances, and
swelling of hands and face. What is the priority nursing action?
A. Encourage rest and hydration
✔✔B. Assess for preeclampsia and notify provider
C. Teach fetal kick counts
D. Monitor blood sugar
A postpartum client reports bright red vaginal bleeding and passage of large clots 3 hours after
delivery. What is the first nursing intervention?
A. Encourage ambulation
✔✔B. Massage the fundus and assess uterine tone
C. Apply perineal pad and document
D. Administer analgesics
A client in labor has a blood pressure of 88/56 mmHg and HR 120 bpm after epidural anesthesia.
What should the nurse do first?
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,A. Administer oxygen
✔✔B. Reposition client to left lateral and increase IV fluids
C. Encourage deep breathing
D. Prepare for emergency delivery
A newborn at 2 hours of life has a heart rate of 75 bpm and weak cry. What is the priority nursing
action?
A. Swaddle the newborn
✔✔B. Stimulate and provide supplemental oxygen
C. Administer vitamin K
D. Delay feeding
A client at 36 weeks gestation presents with sudden abdominal pain and no fetal movement.
What is the priority assessment?
A. Encourage hydration
✔✔B. Assess fetal heart rate and prepare for emergency evaluation
C. Administer analgesics
D. Measure fundal height
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,A postpartum client reports severe perineal pain and swelling after delivery. What is the priority
nursing intervention?
A. Apply warm sitz bath immediately
✔✔B. Apply cold compress and assess for hematoma
C. Encourage ambulation
D. Document findings only
A client with gestational diabetes is unsure how to monitor blood glucose at home. What is the
best teaching?
A. Check blood sugar once a week
B. Skip insulin on low-glucose days
✔✔C. Teach fingerstick technique, target levels, and diet management
D. Monitor only if symptoms appear
A client in labor develops variable decelerations on fetal monitor. What is the priority nursing
intervention?
A. Continue monitoring
B. Encourage Valsalva maneuver
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, ✔✔C. Reposition client, administer oxygen, and notify provider
D. Administer IV fluids only
A breastfeeding client reports nipple pain and cracks. What is the priority nursing action?
A. Encourage formula feeding
B. Apply alcohol to nipples
✔✔C. Assess latch and provide teaching on proper positioning
D. Limit feeding duration
A newborn at 24 hours old shows jaundice with a bilirubin of 14 mg/dL. What is the priority
intervention?
A. Delay feeding
✔✔B. Encourage frequent breastfeeding and monitor bilirubin
C. Administer IV fluids only
D. Prepare for immediate phototherapy
A client at 32 weeks gestation reports generalized pruritus and dark urine. What condition should
the nurse suspect?
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