Nokea
A 28-year-old multigravid client at 28 weeks' gestation diagnosed with acute pyelonephritis is receiving intravenous fluids and antibiotics. After teaching the client about the rationale for the aggressive therapy, the nurse determines that the client needs further instruction when she says that acute pyelonephritis can lead to which of the following?
- A. Preterm labor.
- B. Maternal sepsis.
- C. Intrauterine growth retardation.
- D. Congenital fetal anomalies.
Correct Answer: D
Rationale: Acute pyelonephritis can cause preterm labor, maternal sepsis, and intrauterine growth retardation due to infection and inflammation. Congenital fetal anomalies are not a direct consequence, indicating a need for further teaching.
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One-half hour after vaginal delivery of a term neonate, the nurse palpates the fundus of a primigravid client, noting several large clots and a small trickle of bright red vaginal bleeding. The client's blood pressure is 136/92 mm Hg. Which of the following would the nurse do first?
- A. Continue to monitor the client's fundus every 15 minutes.
- B. Ask the physician for an order for methylergonovine (Methergine).
- C. Immediately notify the physician of the client's symptoms.
- D. Change the client's perineal pads every 15 minutes.
Correct Answer: C
Rationale: Large clots and bright red bleeding post-delivery suggest possible uterine atony or retained placental fragments, requiring immediate physician notification for intervention. Monitoring, requesting medication, or changing pads are secondary actions.
Which of the following should the nurse include in the discharge teaching for a primiparous client about preventing postpartum infections?
- A. Change perineal pads every 8 hours.
- B. Take warm sitz baths twice daily.
- C. Wash hands before and after perineal care.
- D. Use a hairdryer to dry the perineal area.
Correct Answer: C
Rationale: Hand washing before and after perineal care reduces the risk of introducing pathogens, preventing infections.
The nurse is completing discharge instructions with a new mother and is concerned about her safety. Which statement by the client indicates the client needs further instructions?
- A. I will need to be checked out by the doctor in a week.
- B. I need to wear a sports bra for a few days so I don't get milk.
- C. I can get pregnant now if I don't use birth control.
- D. I may feel sad for a few days but should be OK within a few days.
Correct Answer: B
Rationale: Wearing a sports bra does not prevent milk production; this statement indicates a misunderstanding of lactation suppression.
The nurse in the newborn nursery has just received shift report about a group of newborns and is to receive another admission in 30 minutes. In order to provide the safest care and plan for the new admission, the nurse should do which of the following in order of first to last?
- A. Move quickly from room to room and assess all clients.
- B. Check the room to which the new client will be admitted to be sure all supplies and equipment are available.
- C. Log on to the clinical information system and determine if there are new orders.
- D. Review notes from shift report and prioritize all clients; make rounds on the most critical first.
Correct Answer: D,C,A,B
Rationale: First, review and prioritize clients (D). Then, check for new orders (C), assess all clients (A), and finally prepare the room for the new admission (B).
During a home visit on the fourth postpartum day, a primiparous client tells the nurse that she is aware of a "let-down sensation" in her breasts and asks what causes it. The nurse explains that the let-down sensation is stimulated by which of the following?
- A. Adrenalin.
- B. Estrogen.
- C. Prolactin.
- D. Oxytocin.
Correct Answer: D
Rationale: Oxytocin triggers the let-down reflex, releasing milk during breastfeeding.