Nokea
A client is postpartum 24 hours from a spontaneous vaginal delivery with rupture of membranes for 42 hours. Which of the following signs/symptoms should the nurse report to the client's health care practitioner?
- A. Foul-smelling lochia.
- B. Engorged breasts.
- C. Cracked nipples.
- D. Cluster of hemorrhoids.
Correct Answer: A
Rationale: Foul-smelling lochia indicates infection.
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A mucousy baby is being left with the parents for the first time after delivery. Which of the following should the nurse teach the parents regarding use of the bulb syringe?
- A. Suction the nostrils before suctioning the mouth.
- B. Make sure to suction the back of the throat.
- C. Insert the syringe before compressing the bulb.
- D. Dispose of the drainage in a tissue or a cloth.
Correct Answer: A
Rationale: Suctioning the nostrils first clears airways effectively.
A woman who wishes to breastfeed advises the nurse that she has had breast augmentation surgery. Which of the following responses by the nurse is appropriate?
- A. Breast implants often contaminate the milk with toxins.
- B. The glandular tissue of women who need implants is often deficient.
- C. Babies often have difficulty latching to the nipples of women with breast implants.
- D. Women who have implants are often able exclusively to breastfeed.
Correct Answer: D
Rationale: Implants do not preclude breastfeeding.
A baby boy is to be circumcised by the mother's obstetrician. Which of the following actions shows that the nurse is being a patient advocate?
- A. Before the procedure
- B. the nurse prepares the sterile field for the physician.
- C. The nurse refuses to unclothe the baby until the doctor orders something for pain.
- D. The nurse holds the feeding immediately before the circumcision.
Correct Answer: B
Rationale: Ensuring pain management demonstrates advocacy for the baby's comfort and safety.
The nurse notes the following vital signs of a postoperative cesarean client during the immediate postpartum period: 100.0°F, P 68, R 12, BP 130/80. Which of the following is a correct interpretation of the findings?
- A. Temperature is elevated, a sign of infection.
- B. Pulse is too low, a sign of vagal pathology.
- C. Respirations are too low, a sign of medication toxicity.
- D. Blood pressure is elevated, a sign of preeclampsia.
Correct Answer: C
Rationale: Low respirations may indicate opioid toxicity.
The nurse is providing care to a patient who delivered a 3525-g infant 14 hours ago. The nurse palpates the fundus of the uterus as firm and at the umbilicus. What is the nurse’s priority action related to this finding?
- A. Inform the health care provider.
- B. Encourage the patient to urinat
- C. Massage the uterus to expel clots.
- D. Document the finding in the patient’s chart.
Correct Answer: D
Rationale: The correct answer is D: Document the finding in the patient’s chart. The fundus being firm and at the umbilicus indicates normal involution after delivery. Documenting this finding is essential for accurate assessment and continuity of care. Informing the health care provider (choice A) is not necessary as the finding is normal. Encouraging the patient to urinate (choice B) is important for postpartum care but not the priority in this situation. Massaging the uterus to expel clots (choice C) is not indicated as the fundus is already firm, indicating proper contraction.