1. A laboring client at –2 station has a spontaneous rupture of the membranes and a cordimmediately 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 sideANSWER: 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 thecord enabling perfusion to the

infant. Turning the client to her left side facilitates better perfusion to themother 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 identifyingpostpartum 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 weekANSWER: 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 fromred 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 understandsthe 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 whohave delivered an rh-positive infant. Rhogam must be given within 72 hours of the delivery of the infant because antibody formation begins at that time. The vaccine is used only when the mother delivered an