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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.
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.
Place the client in the knee-chest position.
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The nurse observes a new mother avoiding eye contact with her newborn. Which
action should the nurse take?
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.
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.
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. Avoid letting the infant suck
on the tube. Insert feeding tube
through nares.
Apply steady pressure to the syringe.
Allow the formula to flow by gravity.
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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.
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.
Increase caloric intake by approximately 500 calories/day.
Double prenatal milk intake to improve Vitamin D transfer to the
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.
Gently rub the infant's feet or back to stimulate respirations and place in the
radiant warmer.
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The nurse tells a client in her first trimester that she should increase her daily
intake of calcium to 1,200 mg during pregnancy. The client responds, "I don't like
milk." Which
dietary adjustments should the nurse recommend?
Increase organ meats in the
diet. Eat more green, leafy
vegetables.
Add molasses and whole-grain bread to the diet.
Choose more fresh citrus and other fruits daily.
Eat more green, leafy vegetables.
A primigravida at 12 weeks gestation tells the nurse that she does not like dairy
products. Which food should the nurse recommend to increase the client's
calcium intake?
Canned
clams.
Fresh
apricots.
Canned sardines.
Spaghetti with meat sauce.
Canned sardines.
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