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A client who delivered vaginally 18 hours ago develops a slight fever. The client's delivery record shows spontaneous rupture of membranes (SROM) for 36 hours prior to delivery and labor lasting 24 hours. An epidural was placed during labor, and she experienced a third-degree perineal laceration. The nurse should recognize which information poses the greatest risk for developing postpartum endometritis?
- A. SROM for 36 hours.
- B. Labor lasting for 24 hours.
- C. Third-degree perineal laceration.
- D. Epidural anesthesia.
Correct Answer: A
Rationale: Prolonged SROM significantly increases the risk of postpartum endometritis due to extended exposure to pathogens.
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The current vital signs for a primipara who delivered vaginally during the previous shift are: temperature 100.4° F (38° C), heart rate 58 beats/minute, respiratory rate 16 breaths/minute, and blood pressure 130/74 mm Hg. Which action should the nurse implement?
- A. Administer a PRN dose of acetaminophen.
- B. Assess perineum for excessive lochia.
- C. Document the vital signs in the record.
- D. Report heart rate to healthcare provider.
Correct Answer: C
Rationale: These vital signs are normal postpartum; documenting them ensures accurate tracking without unnecessary interventions.
A woman in her third trimester of pregnancy has been in active labor for the past 8 hours and has dilated 3 cm. The nurse's assessment findings and electronic fetal monitoring (EFM) are consistent with hypotonic dystocia, and the healthcare provider (HCP) prescribes an oxytocin drip. Which data is most important for the nurse to monitor?
- A. Preparation for emergency cesarean birth.
- B. Intensity, interval, and length of contractions.
- C. Checking the perineum for bulging.
- D. Client's hourly blood pressure.
Correct Answer: B
Rationale: Monitoring contraction patterns ensures oxytocin efficacy and prevents hyperstimulation in hypotonic dystocia, critical for labor progression.
A client receiving a solution of magnesium sulfate suddenly develops right upper quadrant pain. After reviewing abnormal laboratory results, what action should the nurse implement? (Select all that apply)
- A. Evaluate fetal heart rate and contraction patterns.
- B. Obtain prescription to repeat hepatic panel.
- C. Monitor for evidence of seizure activity.
- D. Check the urinary output in hourly urinometer.
- E. Inspect the perineum for vaginal bleeding.
Correct Answer: A,B,C,D
Rationale: Monitoring fetal heart rate, repeating hepatic panel, checking for seizures, and assessing urinary output address potential HELLP syndrome and renal function in preeclampsia.
The client has experienced an eclamptic seizure. Which of the following interventions by the nurse will help stabilize the client? (Select all that apply)
- A. Explaining procedures.
- B. Treating nausea.
- C. Ensuring side rails are padded.
- D. Assisting with breast pumping.
- E. Evaluating blood pressure frequently.
- F. Evaluating for headache.
- G. Assessing deep tendon reflexes.
Correct Answer: C,E,G,H
Rationale: Padded side rails, frequent blood pressure checks, reflex assessment, and minimizing visitors stabilize the client by preventing injury, monitoring hypertension, and reducing seizure triggers.
A woman who is trying to get pregnant tells the nurse that she was very disappointed several months ago when she was informed that her positive pregnancy test was a false positive. Which method of determining pregnancy provides the greatest degree of accuracy?
- A. Visualization of implantation by vaginal ultrasound.
- B. Maternal blood serum tests positive for alpha-fetoprotein.
- C. Presence of amenorrhea for 2 months.
- D. Reports feeling tired all of the time.
Correct Answer: A
Rationale: Vaginal ultrasound directly visualizes the implanted embryo, providing the highest accuracy compared to biochemical tests or subjective symptoms, which can be misleading.