Try our free nursing testbanks today. click here to join
Teas 7 test, Hesi A2 and Nursing prep
Nursingprepexams LEARN. PREPARE. EXCEL!
  • Home
  • Nursing
  • TEAS
  • HESI
  • Blog
Start Studying Now

Take full exam for free

A nurse is caring for a client in the fourth stage of labor after a vaginal delivery.

History and Physical:

BP: 144/92 mmHg.

Pulse: 99 bpm.
Respirations: 17/min.

Pulse Ox: 97%.

Temperature: 100.4 F (38.0 C).

Pain score: 1/10.

The nurse should first address the client's ____________ (assessment finding), followed by the client's ____________ (assessment finding).

A.

Blood pressure.

B.

Pulse.

C.

Respirations.

D.

Temperature.

E.

Temperature.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Blood pressure should be addressed first due to the client’s elevated BP (144/92 mmHg), which is a potential sign of complications such as preeclampsia.

 

Choice B rationale

Pulse of 99 bpm is slightly elevated but not immediately concerning compared to the high BP.

 

Choice C rationale

Respirations are within normal range (17/min) and do not require immediate intervention.

 

Choice D rationale

Temperature of 100.4°F (38.0°C) is slightly elevated but not as critical as the high BP.


Free Nursing Test Bank

  1. Free Pharmacology Quiz 1
  2. Free Medical-Surgical Quiz 2
  3. Free Fundamentals Quiz 3
  4. Free Maternal-Newborn Quiz 4
  5. Free Anatomy and Physiology Quiz 5
  6. Free Obstetrics and Pediatrics Quiz 6
  7. Free Fluid and Electrolytes Quiz 7
  8. Free Community Health Quiz 8
  9. Free Promoting Health across the Lifespan Quiz 9
  10. Free Multidimensional Care Quiz 10
Take full exam free

View Related questions

Correct Answer is B

Explanation

Choice A rationale

Prophylactic treatment for cytomegalovirus during pregnancy isn't generally recommended. CMV detection should lead to close monitoring rather than prophylactic treatment, as

current treatments pose risks without guaranteed efficacy.

Choice B rationale

Avoiding cat litter is crucial during pregnancy to prevent toxoplasmosis infection, which can cause severe fetal harm, including hydrocephalus, mental disabilities, and seizures, by

transferring through contact with cat feces.

Choice C rationale

While avoiding crowded places can reduce general infection risks, it is not specifically associated with preventing TORCH infections. TORCH infections refer to a set of perinatal infections that pose particular risks to fetal health.

Choice D rationale

Rubella immunization should be done before pregnancy, not during, as live vaccines carry risks. A woman should confirm immunity before conception to protect against congenital rubella syndrome.

Correct Answer is ["B","D","F"]

Explanation

Choice A rationale:

Supplementing with formula is not necessary based on the given information. The baby is voiding and passing stools adequately, indicating proper feeding. Instead, feeding on demand and ensuring frequent breastfeeding will help address any concerns about the baby's weight.

Choice B rationale:

Feeding 8 to 12 times per day and on demand is recommended to ensure adequate milk supply and proper growth and development of the newborn. Frequent feeding helps to establish and maintain milk production.

Choice C rationale:

Using plastic-lined breast pads is not recommended as they can trap moisture and create an environment that promotes nipple irritation and infection. It is better to use breathable, non-plastic-lined breast pads.

Choice D rationale:

It is correct that a newborn's stools should transition from the dark greenish color meconium to a yellow color within a few days as the baby begins digesting breast milk.

Choice E rationale:

Drinking more whole milk does not directly increase a mother's milk supply. Milk supply is primarily regulated by the frequency and efficiency of breastfeeding or pumping.

Choice F rationale:

Expecting the breasts to feel full, warm, and slightly tender when the milk comes in is accurate. This usually occurs around the third or fourth day postpartum and indicates that the milk production process is underway.

Quick Links

Nursing Teas Hesi Blog

Resources

Nursing Test banks Teas Prep Hesi Prep Nursingprepexams Blogs
© Nursingprepexams.com @ 2019 -2025, All Right Reserved.