Question

A nurse in the labor and delivery unit is caring for a client who is undergoing external fetal monitoring. The nurse observes that the fetal heart rate begins to slow after the start of a contraction and the lowest rate occurs after the peak of the contraction. Which of the following actions should the nurse take first?

Answer 1

Correct Answers:

Place the client in the lateral position.

Rationale :

🔷 Late decelerations indicate uteroplacental insufficiency, and the first priority is to improve uterine perfusion and oxygenation.

🔷 Placing the client in a lateral position reduces pressure on the vena cava, improves blood flow to the uterus and fetus, and helps resolve decelerations.

🔷 This is the least invasive and most immediate intervention.

🔷 Other interventions such as oxygen administration and IV fluid bolus may follow if late decelerations persist.

🔷 Positioning helps restore optimal fetal oxygenation and cardiac output.

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Answer 2

Correct Answers:

Respiratory rate of 16/min

Rationale :

🟢 Magnesium sulfate toxicity can suppress the central nervous system, leading to respiratory depression.

🟢 A respiratory rate of 16/min is within the safe range (>12/min), indicating that respiratory compromise is not occurring.

🟢 The nurse must monitor DTRs, urine output, and respiratory rate to determine magnesium toxicity risk.

🟢 A urine output above 30 mL/hr and the presence of DTRs are additional safety indicators.

🟢 A stable respiratory rate ensures safe continuation of the infusion for seizure prophylaxis in preeclampsia.

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Answer 3

Correct Answers:

What part of the exam makes you most nervous?

Rationale :

🔶 This open-ended, therapeutic question encourages the client to express her concerns, promoting trust and individualized support.

🔶 It reflects the principle of client-centered communication, especially important for adolescents facing sensitive procedures.

🔶 Rather than dismissing the fear, the nurse shows empathy and understanding, building a supportive relationship.

🔶 This approach also helps uncover misconceptions or fears the client may have.

🔶 The nurse can then tailor education or reassurance based on the client’s specific worries.

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Answer 4

Correct Answers:

The mother plans to use a cotton-tipped swab to clean the nares.

Rationale :

🟣 Using a cotton-tipped swab in the newborn's nares can cause trauma to delicate nasal tissues or push secretions deeper.

🟣 The nurse should intervene to prevent possible injury or obstruction.

🟣 Gentle cleaning of the nose should be done externally with a soft cloth, and saline drops can be used if necessary.

🟣 The other actions—leaving yellow exudate, cleaning cord with tap water, and wiping eyes inner to outer—are appropriate.

🟣 Proper guidance during the first bath promotes safe newborn care practices.

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Answer 5

Correct Answers:

We can time your pain medication so that you have an hour or two before the next feeding.

Rationale :

⚪ This response acknowledges the mother’s concern and provides a safe, evidence-based strategy for pain relief during breastfeeding.

⚪ Timing medications between feedings allows peak drug levels to decrease before the next nursing session.

⚪ Most medications are safe in breastfeeding and healthcare providers aim to minimize infant exposure.

⚪ Supporting maternal comfort encourages effective breastfeeding and postpartum recovery.

⚪ The nurse should always balance medication safety with maternal well-being.

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Answer 6

Correct Answers:

Iron stores in infants begin to deplete.

Rationale :

🟠 Infants are born with maternal iron stores that usually begin to deplete around 4 to 6 months of age.

🟠 Iron-fortified formula is recommended when transitioning from breast milk to prevent iron-deficiency anemia.

🟠 This teaching supports appropriate nutritional planning during infancy.

🟠 Iron is well absorbed in infants, especially when paired with vitamin C.

🟠 Proper iron intake is critical for neurologic development and hemoglobin production.

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Answer 7

Correct Answers:

Peanut butter

Rationale :

🟥 Phenylketonuria (PKU) is a genetic disorder where the body cannot metabolize phenylalanine, an amino acid found in high-protein foods like peanut butter.

🟥 Consuming such foods leads to accumulation of phenylalanine, which can cause brain damage and developmental issues.

🟥 Pregnant clients with PKU must follow a strict low-phenylalanine diet to prevent fetal complications.

🟥 Low-protein fruits and vegetables like apple juice and broccoli are usually safe.

🟥 The nurse should educate clients with PKU early in pregnancy about diet adherence.

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Answer 8

Correct Answers:

Empty her bladder immediately prior to the procedure.

Rationale :

✳️ At 23 weeks, the uterus is an abdominal organ and a full bladder could displace the uterus, increasing the risk of complications during amniocentesis.

✳️ The bladder should be emptied immediately before the procedure to allow better visualization and reduce risk of puncture.

✳️ Bowel prep is not needed, and fasting is unnecessary for amniocentesis.

✳️ The abdomen should be clean, but no special washing protocol is required.

✳️ Proper prep enhances safety and accuracy of the procedure.

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Answer 9

Correct Answers:

A client who is experiencing preterm labor at 26 weeks of gestation.

Rationale :

🟩 Tocolytics, such as nifedipine or terbutaline, are used to delay preterm labor, ideally before 34 weeks to allow time for lung maturity treatments like corticosteroids.

🟩 At 26 weeks, delaying labor can greatly improve neonatal outcomes.

🟩 Tocolytics are not used in term or post-term pregnancies, nor in cases of fetal demise.

🟩 The goal is to prevent early delivery and reduce the risk of neonatal morbidity and mortality.

🟩 Assessing gestational age is key before initiating tocolytic therapy.

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Answer 10

Correct Answers:

Zinc intake should be at least 12 mg per day.

Rationale :

🟦 During lactation, zinc requirements increase due to transfer into breast milk.

🟦 A daily intake of 12 mg supports maternal immunity and infant development.

🟦 Iron needs actually decrease postpartum, and calcium remains the same as pregnancy (about 1,000 mg/day).

🟦 Folic acid requirements decrease slightly, as neural tube development is complete.

🟦 Proper nutrient education ensures optimal maternal and infant health during lactation.

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QLexNursing

2 :
A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate IV at 2 g/hr. Which of the following findings indicates that it is safe for the nurse to continue the infusion?

3 :
A nurse in a family planning clinic is caring for a 17-year-old female client who is requesting oral contraceptives. The client states that she is nervous because she has never had a pelvic examination. Which of the following responses should the nurse make?

4 :
A nurse is observing a new mother bathing her newborn son for the first time. For which of the following actions should the nurse intervene?

5 :
A nurse is caring for a client who is beginning to breastfeed her newborn after delivery. The new mother states, "l don't want to take anything for pain because I am breastfeeding." Which of the following statements should the nurse make?

6 :
A nurse in a clinic is teaching the mother of a 4-month-old infant who has been breastfed. The mother plans to switch her infant to an iron-fortified formula. Which of the following should be included in the teaching?

7 :
A nurse is providing teaching to a client who is pregnant and has phenylketonuria (PKU). Which of the following foods should the nurse instruct the client to eliminate from her diet?

8 :
A nurse is teaching a client who is at 23 weeks of gestation and will return to the facility in 2 days for an amniocentesis. Which of the following instructions should the nurse give the client?

9 :
A nurse is caring for several clients. The nurse should recognize that it is safe to administer tocolytic therapy to which of the following clients?

10 :
A nurse in a prenatal clinic is teaching a group of clients about nutrition requirements during lactation. Which of the following statements should the nurse make?

QLexNursing

2 : A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate IV at 2 g/hr. Which of the following findings indicates that it is safe for the nurse to continue the infusion?

3 : A nurse in a family planning clinic is caring for a 17-year-old female client who is requesting oral contraceptives. The client states that she is nervous because she has never had a pelvic examination. Which of the following responses should the nurse make?

4 : A nurse is observing a new mother bathing her newborn son for the first time. For which of the following actions should the nurse intervene?

5 : A nurse is caring for a client who is beginning to breastfeed her newborn after delivery. The new mother states, "l don't want to take anything for pain because I am breastfeeding." Which of the following statements should the nurse make?

6 : A nurse in a clinic is teaching the mother of a 4-month-old infant who has been breastfed. The mother plans to switch her infant to an iron-fortified formula. Which of the following should be included in the teaching?

7 : A nurse is providing teaching to a client who is pregnant and has phenylketonuria (PKU). Which of the following foods should the nurse instruct the client to eliminate from her diet?

8 : A nurse is teaching a client who is at 23 weeks of gestation and will return to the facility in 2 days for an amniocentesis. Which of the following instructions should the nurse give the client?

9 : A nurse is caring for several clients. The nurse should recognize that it is safe to administer tocolytic therapy to which of the following clients?

10 : A nurse in a prenatal clinic is teaching a group of clients about nutrition requirements during lactation. Which of the following statements should the nurse make?

2 :
A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate IV at 2 g/hr. Which of the following findings indicates that it is safe for the nurse to continue the infusion?

3 :
A nurse in a family planning clinic is caring for a 17-year-old female client who is requesting oral contraceptives. The client states that she is nervous because she has never had a pelvic examination. Which of the following responses should the nurse make?

4 :
A nurse is observing a new mother bathing her newborn son for the first time. For which of the following actions should the nurse intervene?

5 :
A nurse is caring for a client who is beginning to breastfeed her newborn after delivery. The new mother states, "l don't want to take anything for pain because I am breastfeeding." Which of the following statements should the nurse make?

6 :
A nurse in a clinic is teaching the mother of a 4-month-old infant who has been breastfed. The mother plans to switch her infant to an iron-fortified formula. Which of the following should be included in the teaching?

7 :
A nurse is providing teaching to a client who is pregnant and has phenylketonuria (PKU). Which of the following foods should the nurse instruct the client to eliminate from her diet?

8 :
A nurse is teaching a client who is at 23 weeks of gestation and will return to the facility in 2 days for an amniocentesis. Which of the following instructions should the nurse give the client?

9 :
A nurse is caring for several clients. The nurse should recognize that it is safe to administer tocolytic therapy to which of the following clients?

10 :
A nurse in a prenatal clinic is teaching a group of clients about nutrition requirements during lactation. Which of the following statements should the nurse make?