Nokea
A home care nurse is following up with a postpartum client. Which of the following is a risk factor that places this client at risk for postpartum depression?
- A. History of anxiety
- B. Socioeconomic status
- C. Hormonal changes with a rapid decline in estrogen and progesterone
- D. Support from family members
Correct Answer: C
Rationale: Postpartum depression can be triggered by various factors, but one of the strongest predictors is a rapid drop in estrogen and progesterone levels following childbirth. These hormonal changes can affect mood regulation, making some women more vulnerable to depression during the postpartum period.
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A nurse is caring for a client who is in the transition phase of labor. Which of the following actions should the nurse take?
- A. Assist the client to void every 3 hr
- B. Monitor contractions every 30 min
- C. Place the client into a lithotomy position
- D. Encourage the client to use a pant-blow breathing pattern
Correct Answer: D
Rationale: Encouraging the client to use a pant-blow breathing pattern helps manage pain and anxiety during the transition phase, which is characterized by intense contractions and emotional responses.
A nurse is providing care to a client with severe preeclampsia. Which of the following medications should the nurse anticipate administering?
- A. Magnesium sulfate
- B. Oxytocin
- C. Misoprostol
- D. Nifedipine
Correct Answer: A
Rationale: Magnesium sulfate is administered to prevent seizures in clients with severe preeclampsia. It acts as a central nervous system depressant and is the first-line treatment for eclampsia prevention.
A nurse is caring for a client who is 8 hours postpartum following a vaginal birth. The client reports passing large clots and heavy bleeding. Which of the following actions should the nurse take?
- A. Massage the fundus
- B. Administer methylergonovine
- C. Increase the IV fluid rate
- D. Notify the healthcare provider
Correct Answer: A
Rationale: Heavy bleeding and the passage of large clots after childbirth can indicate uterine atony. The nurse should first attempt to massage the fundus to stimulate uterine contractions and control the bleeding.
A nurse is providing teaching to a client who is 32 weeks pregnant and has a diagnosis of placenta previa. Which of the following instructions should the nurse include?
- A. Limit physical activity
- B. Monitor fetal movements daily
- C. Call the healthcare provider if contractions begin
- D. All of the above
Correct Answer: D
Rationale: Clients with placenta previa are at increased risk for bleeding and preterm labor. They should limit physical activity, monitor fetal movements, and notify their provider if they experience any contractions or signs of labor.
A nurse is providing education to a client who is 28 weeks pregnant and at risk for preterm labor. Which of the following signs should the nurse instruct the client to report immediately?
- A. Lower back pain
- B. Shortness of breath
- C. Decreased fetal movement
- D. Nausea and vomiting
Correct Answer: A
Rationale: Lower back pain, especially if accompanied by uterine contractions or pressure, can be a sign of preterm labor. The client should report this immediately to prevent complications or early delivery.