Nokea
A client is 1 hour postpartum and the nurse observes a large amount of lochia rubra and several small clots on the client's perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take?
- A. Notify the healthcare provider.
- B. Increase the frequency of fundal massage.
- C. Encourage the client to empty their bladder.
- D. Document the findings and continue to monitor the client.
Correct Answer: D
Rationale: Rationale:
1. Lochia rubra and small clots are expected postpartum.
2. The firm, midline fundus indicates normal involution.
3. No signs of excessive bleeding or fundus displacement.
4. Documenting and monitoring is appropriate for normal postpartum assessment.
Summary:
A: Not necessary as no complications present.
B: Unnecessary and could cause discomfort.
C: Bladder emptying may help fundal position but not urgent.
D: Correct option for normal postpartum assessment and monitoring.
You may also like to solve these questions
A parent of a newborn is being taught about crib safety. Which statement by the client indicates understanding of the teaching?
- A. I will place my baby on his stomach when he is sleeping.
- B. I should remove extra blankets from my baby's crib.
- C. I should pad the mattress in my baby's crib so that he will be more comfortable when he sleeps.
- D. I should place my baby's crib next to the heater to keep him warm during the winter.
Correct Answer: B
Rationale: The correct answer is B because removing extra blankets from the baby's crib reduces the risk of suffocation and Sudden Infant Death Syndrome (SIDS). Placing the baby on the stomach (Option A) increases the risk of SIDS. Padding the mattress (Option C) can also increase the risk of suffocation. Placing the crib next to a heater (Option D) can lead to overheating and poses a fire hazard. Removing extra blankets ensures a safe sleep environment for the baby.
During an assessment of a client in labor who received epidural anesthesia, which finding should the nurse identify as a complication of the epidural block?
- A. Vomiting
- B. Tachycardia
- C. Respiratory depression
- D. Hypotension
Correct Answer: D
Rationale: The correct answer is D: Hypotension. Epidural anesthesia can lead to hypotension due to vasodilation and sympathetic blockade, resulting in decreased blood pressure. This is a common complication that nurses should monitor for and manage promptly. Vomiting (A) is not a direct complication of epidural anesthesia. Tachycardia (B) is not typically associated with epidural anesthesia but may indicate other issues. Respiratory depression (C) is more commonly seen with opioids and not a typical complication of epidural anesthesia.
A client is scheduled for a cesarean birth based on fetal lung maturity. Which finding indicates that the fetal lungs are mature?
- A. Absence of Phosphatidylglycerol (PG)
- B. Biophysical profile score of 8
- C. Lecithin/sphingomyelin (L/S) ratio of 2:1
- D. Reactive nonstress test
Correct Answer: C
Rationale: The correct answer is C: Lecithin/sphingomyelin (L/S) ratio of 2:1. This ratio indicates fetal lung maturity as it signifies adequate production of surfactant in the fetal lungs, essential for proper lung function after birth. Absence of Phosphatidylglycerol (PG) (Choice A) indicates immaturity, Biophysical profile score of 8 (Choice B) assesses overall fetal well-being, not lung maturity, and Reactive nonstress test (Choice D) evaluates fetal well-being, not lung maturity. The L/S ratio of 2:1 is the most reliable indicator of fetal lung maturity.
A healthcare professional in the emergency department is caring for a client who presents with severe abdominal pain in the left lower quadrant. The provider suspects a ruptured ectopic pregnancy. Which of the following signs indicates to the healthcare professional that the client has blood in the peritoneum?
- A. Chvostek's sign
- B. Cullen's sign
- C. Chadwick's sign
- D. Goodell's sign
Correct Answer: B
Rationale: The correct answer is B: Cullen's sign. Cullen's sign is the presence of periumbilical ecchymosis, indicating blood in the peritoneum due to internal bleeding from a ruptured ectopic pregnancy. Chvostek's sign (choice A) is related to facial muscle spasm due to hypocalcemia. Chadwick's sign (choice C) is bluish discoloration of the cervix indicating pregnancy. Goodell's sign (choice D) is softening of the cervix in early pregnancy. These signs are not indicative of blood in the peritoneum like Cullen's sign is.
A client in active labor has 7 cm of cervical dilation, 100% effacement, and the fetus at 1+ station. The client's amniotic membranes are intact, but she suddenly expresses the need to push. What should the nurse do?
- A. Assist the client into a comfortable position.
- B. Observe the perineum for signs of crowning.
- C. Have the client pant during the next contractions.
- D. Help the client to the bathroom to void.
Correct Answer: C
Rationale: Rationale: Option C, having the client pant during the next contractions, is the correct answer. At 7 cm dilation with a sudden urge to push, it indicates possible fetal descent. Panting can help prevent rapid descent and reducing the risk of cervical edema or injury. It allows time for the cervix to dilate fully before pushing, preventing premature pushing and potential complications. Option A is not a priority at this stage. Option B is incorrect as observing for crowning might lead to premature pushing. Option D is not necessary as voiding is not the priority right now.