Nokea
A client's vital signs and reflexes were normal throughout pregnancy, labor, and delivery. Four hours after delivery the client's vitals are 98.6°F, P 72, R 20, BP 150/100, and her reflexes are 4+. She has an intravenous infusion running with 20 units of Pitocin (oxytocin) added. Which of the following actions by the nurse is appropriate?
- A. Nothing, because the results are normal.
- B. Notify the obstetrician of the findings.
- C. Discontinue the intravenous immediately.
- D. Reassess the client after fifteen minutes.
Correct Answer: B
Rationale: Elevated blood pressure requires medical evaluation.
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The nurse is performing a postpartum assessment on a client who delivered 4 hours ago. The nurse notes a firm uterus at the umbilicus with heavy lochial flow. Which of the following nursing actions is appropriate?
- A. Massage the uterus.
- B. Notify the obstetrician.
- C. Administer an oxytocic as ordered.
- D. Assist the client to the bathroom.
Correct Answer: C
Rationale: Oxytocics help control uterine atony and bleeding.
A nurse is doing a newborn assessment on a new admission to the nursery. Which of the following actions should the nurse make when evaluating the baby for developmental dysplasia of the hip (DDH)? Select one that doesn't apply
- A. Grasp the baby's legs with the thumbs on the inner thighs and forefingers on the outer thighs.
- B. Gently adduct and abduct the baby's thighs.
- C. Palpate the trochanter during hip rotation.
- D. Place the baby in a fetal position.
Correct Answer: D
Rationale: These maneuvers help detect instability or asymmetry in the hips indicative of DDH.
A mother asks whether or not she should be concerned that her baby never opens his mouth to breathe when his nose is so small. Which of the following is the nurse's best response?
- A. The baby does rarely open his mouth but you can see that he isn't in any distress.
- B. Babies usually breathe in and out through their noses so they can feed without choking.
- C. Everything about babies is small. It truly is amazing how everything works so well.
- D. You are right. I will report the baby's small nasal openings to the pediatrician right away.
Correct Answer: B
Rationale: Nasal breathing is normal in newborns to allow simultaneous feeding and breathing.
A postpartum patient asks, “Will these stretch marks ever go away?” Which is the nurse’s best response?
- A. “No, never.”
- B. “Yes, eventually.”
- C. “They will fade to silvery lines but won’t disappear completely.”
- D. “They will continue to fade and should be gone by your 6-week checkup.”
Correct Answer: C
Rationale: The correct answer is C: “They will fade to silvery lines but won’t disappear completely.” This response is the best because it provides a realistic expectation to the patient. Stretch marks may lighten over time but typically do not completely disappear. Choice A is incorrect as it provides a definitive and discouraging answer. Choice B is vague and does not offer a clear timeframe. Choice D is incorrect as it gives an overly optimistic timeline that may not be realistic for most individuals. Overall, choice C is the most accurate and supportive response for the patient's query.
The blood glucose of a client with type 1 diabetes 12 hours after delivery is 96 mg/dL. The client has received no insulin since delivery. The drop in serum levels of which of the following hormones of pregnancy is responsible for the glucose level?
- A. Estrogen.
- B. Progesterone.
- C. Human placental lactogen (hPL).
- D. Human chorionic gonadotropin (hCG).
Correct Answer: C
Rationale: hPL influences glucose metabolism.