Nokea
The nurse is assessing a postpartum client who delivered 2 hours ago. What finding requires immediate action?
- A. Fundus firm and midline.
- B. Lochia rubra with small clots.
- C. Boggy fundus above the umbilicus.
- D. Client reports perineal discomfort.
Correct Answer: C
Rationale: A boggy fundus indicates uterine atony, increasing the risk of hemorrhage.
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Which of the following is an example of healthy grieving?
- A. The mother exhibits an absence of crying or expression of feelings.
- B. The parents do not mention the baby in conversation with family members.
- C. The mother asks that the baby be taken away from the delivery area quickly.
- D. While holding the baby, the mother says to her husband, "He has your eyes and nose."
Correct Answer: D
Rationale: Option D, while holding the baby, the mother saying to her husband, "He has your eyes and nose," is an example of healthy grieving. In this scenario, the mother is acknowledging the baby, expressing emotions, and involving her partner in the process. Verbalizing thoughts and emotions, as well as creating meaningful connections with relevant support persons, are important aspects of healthy grieving. Sharing memories and recognizing the physical similarities between the baby and family members can be therapeutic in the grieving process.
The nurse teaches a new mother that neonatal weight loss in the first 3 days of life is most often the result of:
- A. Allergy to formula
- B. a hypoglycemic response
- C. Inadequate breast or formula feeding
- D. Excretion of fluid via lungs, urinary bladder and bowels.
Correct Answer: D
Rationale: Fluid loss is the primary cause of early weight loss.
The nurse notes that an older adult client receives only one visitor and asks the client if family members could be called. The client states, 'I consider her to be all of my family.' What would the nurse consider in responding to the client?
- A. The nurse could encourage the client to reconnect with other family members.
- B. The client defines who is and who is not part of the family without undue influence.
- C. The nurse realizes individuals exist without a family and do not often adopt substitutes.
- D. Family is more important to those individuals with a large number of family members.
Correct Answer: B
Rationale: It is important for nurses to remain neutral to all they hear and see in order to enhance trust and maintain open communication lines with all family members. Nurses need to remember that clients are experts of their own health and can define their own family.
A nurse is teaching a prenatal class regarding false labor. Which of the following information should the nurse include?
- A. "Your contraction will become more intense when walking"
- B. "You will have dilation and effacement of the cervix"
- C. You will have bloody show"
- D. "Your contraction will become temporally regular"
Correct Answer: D
Rationale: False labor, also known as Braxton Hicks contractions, are contractions that are irregular and do not lead to cervical dilation and effacement, unlike true labor contractions. During false labor, contractions may feel intense when walking, but they do not become progressively more intense over time, as is seen in true labor. Additionally, false labor contractions do not typically result in bloody show, which is a sign of impending true labor. Therefore, the correct information to include regarding false labor is that contractions will remain temporarily irregular in nature.
What is the first action for a mother experiencing excessive bleeding two hours postpartum?
- A. Monitor blood pressure and heart rate
- B. Perform uterine massage to stimulate contractions
- C. Prepare for a possible blood transfusion
- D. Notify the healthcare provider immediately
Correct Answer: A
Rationale: Uterine massage stimulates contractions, which can reduce postpartum bleeding.