NURSING FUNDAMENTALS HEALTH CARE A EXAM 2023 A GRADE QUESTIONS WITH ANSWERS LATEST UPDATES
1. A laboring client at –2 station has a spontaneous rupture
... [Show More] of the membranes and a cord immediately protrudes from the vagina. The highest priority is which of the following?
a. Place gentle pressure upward on the fetal head
b. Place the cord back into the vagina to keep it moist
c. Begin oxygen by face mask at 8-10l/min
d. Turn the client of her left side ANSWER: A
RATIONALE: The nurse should place her hand on the fetal head and provide gentle upward pressure to relieve the compression on the cord. Doing so allows oxygen to continue flowing to the fetus. The cord should never be placed back into the vagina because doing so may further compress it. Administering oxygen is an appropriate measure but will not serve a useful purpose until the pressure is relieved on the cord enabling perfusion to the infant. Turning the client to her left side facilitates better perfusion to the mother but until the compression on the cord is relieved the increased oxygen will not serve its purpose. Placing the client in a trendelenburg would be position changes to increase perfusion to then infant by relieving cord compression
2. A postpartum client is being discharged part of the discharge teaching plan involves identifying postpartum hemorrhage. The discharge instructions would include reporting which of the following?
a. Bleeding that becomes lighter each day
b. Clots the size of golf balls
c. Saturating a pad in an hour
d. Lochia that last longer than 1 week ANSWER: C
RATIONALE: A postpartum client who saturates a pad in an hour or less at any time in the postpartum period is considered to be hemorrhaging. As the normal postpartum client heals bleeding changes from red to pink to off white. It also decreases in amount each day. Passing blood clots the size of a fist or larger is a reportable problem. Lochia varies in how long it lasts and is considered normal up tp 6 weeks postpartum
3. postpartum client is rh-negative and has delivered an rh-positive infant. The client is being educated concerning rhogam which has been ordered. The nurse realizes the client understands the purpose of rhogam when she states.
a. “Rhogam will protect my next baby if it is rh-negative.”
b. “Rhogam will prevent antibody formation in my blood.”
c. “Rhogam will be given to prevent german measles.”
d. “Rhogam will be used to prevent bleeding in my newborn.” ANSWER: B
RATIONALE: Rhogam is given to new mothers who are rh-negative and not previously sensitized and who have delivered an rh-positive infant. Rhogam must be given within 72 hours of the delivery of the infant because anti-body formation begins at that time. The vaccine is used only when the mother delivered an
rh-positive infant, not an rh-negative. Rhogam [Show Less]