Nokea
The nurse is monitoring a postpartum client with a boggy uterus. What is the priority intervention?
- A. Notify the healthcare provider.
- B. Massage the fundus until firm.
- C. Administer prescribed oxytocin.
- D. Check the client’s vital signs.
Correct Answer: B
Rationale: Massaging a boggy uterus stimulates contraction and reduces the risk of postpartum hemorrhage.
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A woman has been having contractions since 4am this morning. At 8am her cervix dilated 5cm. Contractions are frequent, mild to moderate in intensity. CPD has been ruled out. After giving her sedation so she can rest, what would anticipate preparing her for?
- A. oxytocin induction
- B. Amnioinfusion
- C. c/s
- D. increased IV infusion
Correct Answer: C
Rationale: The scenario describes a woman in active labor with frequent, mild to moderate contractions and significant cervical dilation. If cephalopelvic disproportion (CPD) has been ruled out and the progress of labor is slow despite sufficient dilation and descent of the fetus, it may indicate cephalopelvic disproportion, failure to progress, or other complications that could necessitate a cesarean section (c/s). In this case, providing sedation to allow for rest suggests that the medical team is considering the possibility of further intervention, such as a c/s, if the labor does not progress effectively despite sufficient dilation. Therefore, preparing the woman for a c/s would be the anticipated next step in her care.
A woman has been in labor for 16 hours. Her cervix is dilated
- A. The fetal presenting part is not engage
- B. The nurse would expect which malpresentation
- C. CPD (prevents presenting part form becoming engage
Correct Answer: A
Rationale: If a woman has been in labor for 16 hours and her cervix is not dilated, it suggests that the fetal presenting part is not engaged. Engagement refers to the descent of the fetal presenting part (usually the head) into the pelvis. When the presenting part is not engaged, it may lead to a prolonged labor as the fetus needs to descend further for labor to progress effectively. This can result in slower cervical dilation and may require interventions to help facilitate engagement, such as position changes or use of gravity-assisted techniques.
A nurse is providing teaching to a client who is at 38 weeks of gestation and has a prescription to receive misoprostol intravaginally. Which of the following statement should the nurse make?
- A. "You will need to stay in a side-lying position for 30 minutes after each dose."
- B. "You will receive an IV infusion of oxytocin 1 hour after your last dose."
- C. " You will receive a magnesium supplement immediately following therapy."
- D. " You will need to have a full bladder before the therapy begins."
Correct Answer: A
Rationale: The correct statement the nurse should make to the client receiving misoprostol intravaginally is, "You will need to stay in a side-lying position for 30 minutes after each dose." This instruction is important because maintaining a side-lying position can help prevent leakage and promote proper absorption of the medication. It enhances the effectiveness of the medication and reduces the risk of its expulsion before absorption, ultimately leading to a better response to the treatment. The other options are not relevant to the administration of misoprostol intravaginally and do not align with best practice for this specific therapy.
The nurse is teaching a client about postpartum depression. What statement indicates understanding?
- A. It’s normal to feel hopeless for several weeks.
- B. Postpartum depression only occurs in first-time mothers.
- C. I should seek help if I feel disconnected from my baby.
- D. It is caused by a lack of support from family.
Correct Answer: C
Rationale: Feeling disconnected from the baby is a common symptom of postpartum depression and should prompt seeking help.
What method of heat loss may occur if a newborn is placed on a cold scale or touch with cold hands:
- A. Conduction (occurs when the infant comes in contact with cold objects)
Correct Answer: A
Rationale: Conduction is the transfer of heat between objects that are in direct contact with each other. In the scenario where a newborn is placed on a cold scale or touched with cold hands, heat loss occurs through conduction. The cold temperature of the scale or hands will draw heat away from the infant's body, leading to a drop in body temperature. It is essential to ensure that newborns are not exposed to cold surfaces or objects for prolonged periods to prevent heat loss through conduction and maintain their body temperature within a safe range.