Answers | Latest Version | 2025/2026 |
Correct & Verified
A client at 30 weeks gestation reports headache, blurred vision, and swelling in hands and face.
What is the priority nursing action?
A. Encourage rest and fluids
✔✔B. Assess for preeclampsia and notify provider
C. Measure fundal height
D. Instruct client on kick counts
A postpartum client reports heavy vaginal bleeding with passage of clots 3 hours after delivery.
What should the nurse do first?
A. Apply perineal pad only
B. Encourage ambulation
✔✔C. Massage the fundus and assess for lacerations or retained placenta
D. Document the bleeding
A client in labor receives oxytocin and develops contractions lasting 90 seconds every 1–2
minutes with late decelerations. What is the priority nursing intervention?
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,A. Encourage deep breathing
✔✔B. Stop the infusion and notify provider
C. Administer pain medication
D. Place client in Trendelenburg position
A newborn is assessed 1 hour after birth with heart rate 80 bpm and weak cry. What is the
immediate nursing action?
A. Administer vitamin K
B. Swaddle the newborn
✔✔C. Provide stimulation and supplemental oxygen
D. Apply phototherapy
A client at 36 weeks gestation reports sudden gush of fluid from the vagina. What is the priority
nursing assessment?
A. Measure fundal height
✔✔B. Assess fetal heart rate and note time of rupture
C. Encourage hydration
D. Prepare for delivery immediately
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,A client with gestational diabetes is unsure how to monitor blood sugar at home. What teaching
is essential?
A. Monitor only if symptomatic
B. Check once a week
✔✔C. Teach fingerstick technique, target glucose levels, and diet management
D. Skip insulin on low-glucose days
A client in labor reports severe back pain with contractions. What non-pharmacologic method
should the nurse suggest?
A. Apply cold packs to the abdomen
B. Limit movement and keep supine
✔✔C. Encourage ambulation, position changes, and counter-pressure
D. Administer IV opioids immediately
A postpartum client reports nipple pain and cracks while breastfeeding. What is the priority
nursing intervention?
A. Encourage formula feeding
B. Apply alcohol to nipples
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, ✔✔C. Assess latch technique and provide positioning education
D. Limit feeding duration
A newborn has a temperature of 36.0°C at 2 hours of life. What is the priority nursing action?
A. Delay feeding
B. Reassess in 12 hours
✔✔C. Provide skin-to-skin contact, warm blankets, and monitor
D. Apply cold compress
A client at 32 weeks gestation reports severe pruritus and dark urine. What condition should the
nurse suspect?
A. Urinary tract infection
B. Gestational diabetes
✔✔C. Intrahepatic cholestasis of pregnancy
D. Hyperemesis gravidarum
A client in labor has variable decelerations on fetal monitoring. What is the priority nursing
intervention?
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