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The nurse is assessing a postpartum client. Which finding requires immediate intervention?
- A. Fundus firm and midline.
- B. Lochia rubra with large clots.
- C. Mild swelling in the perineal area.
- D. Breast tenderness on day 2 postpartum.
Correct Answer: B
Rationale: The correct answer is B because Lochia rubra with large clots could indicate excessive bleeding, which is a postpartum hemorrhage and requires immediate intervention to prevent further complications. A: Fundus firm and midline is a normal finding. C: Mild swelling in the perineal area is expected after childbirth. D: Breast tenderness on day 2 postpartum is a common finding due to milk production starting.
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A client at 10 weeks' gestation reports frequent nausea. What dietary advice should the nurse provide?
- A. Consume small, frequent meals throughout the day.
- B. Avoid eating before going to bed.
- C. Drink large amounts of fluids with meals.
- D. Eat only three large meals daily.
Correct Answer: A
Rationale: The correct answer is A. Consuming small, frequent meals helps manage nausea by preventing an empty stomach, which can worsen symptoms. Eating smaller meals throughout the day can help stabilize blood sugar levels and provide a constant source of nutrients. This approach is recommended for managing nausea during early pregnancy.
Choice B is incorrect because avoiding eating before bed does not address the underlying issue of nausea during the day.
Choice C is incorrect because drinking large amounts of fluids with meals may worsen nausea by causing bloating and discomfort.
Choice D is incorrect because eating only three large meals daily can lead to periods of fasting in between meals, which may exacerbate nausea.
The nurse is monitoring a postpartum client. What finding requires immediate action?
- A. Fundus firm and midline.
- B. Lochia rubra with large clots.
- C. Mild perineal discomfort.
- D. Slight swelling of the feet.
Correct Answer: B
Rationale: The correct answer is B because Lochia rubra with large clots may indicate excessive bleeding or a possible postpartum hemorrhage, which requires immediate intervention to prevent complications. A: Fundus firm and midline is a normal finding postpartum. C: Mild perineal discomfort is expected after childbirth. D: Slight swelling of the feet is common due to fluid shifts and does not require immediate action.
A client at 39 weeks' gestation reports sudden gush of fluid. What is the nurse's priority action?
- A. Perform a sterile vaginal exam.
- B. Assess fetal heart rate.
- C. Check maternal vital signs.
- D. Administer IV fluids.
Correct Answer: B
Rationale: The correct answer is B: Assess fetal heart rate. The priority action in this situation is to assess the well-being of the fetus since the client reported a sudden gush of fluid, which could indicate rupture of membranes. Assessing the fetal heart rate helps determine if the fetus is experiencing distress. Performing a sterile vaginal exam (A) can introduce infection and is not the priority. Checking maternal vital signs (C) can be done after assessing the fetal well-being. Administering IV fluids (D) is not the priority until the fetal status is determined.
A client at 30 weeks' gestation is receiving corticosteroids. What is the primary purpose of this therapy?
- A. To prevent preterm labor.
- B. To enhance fetal lung maturity.
- C. To reduce maternal blood pressure.
- D. To lower blood glucose levels.
Correct Answer: B
Rationale: The correct answer is B: To enhance fetal lung maturity. Corticosteroids given to a client at 30 weeks' gestation help accelerate fetal lung maturation, reducing the risk of respiratory distress syndrome in the newborn. This therapy does not prevent preterm labor but rather prepares the baby's lungs for potential early delivery. It also does not directly impact maternal blood pressure or blood glucose levels. Therefore, the primary purpose of corticosteroid therapy in this scenario is to benefit the baby's lung development, making option B the correct choice.
What is the priority nursing care associated with oxytocin infusion?
- A. Monitoring uterine response (don't want it to ruptur
- C. Measuring urinary output
- D. Check cervical dilation
Correct Answer: A
Rationale: The correct answer is A because monitoring uterine response is crucial when administering oxytocin infusion to prevent uterine hyperstimulation and rupture. This involves assessing contraction frequency, duration, and strength. Measuring urinary output (choice C) is important for overall fluid balance but not directly related to oxytocin infusion. Checking cervical dilation (choice D) is not a priority when administering oxytocin. Choice B is incomplete.