Nokea
A nurse in an antepartum unit is triaging clients. Which of the following clients should the nurse see first?
- A. A client who is at 38 weeks of gestation and reports a cough and fever
- B. A client who has missed a period and reports vaginal spotting
- C. A client who is at 14 weeks of gestation and reports nausea and vomiting
- D. A client who is at 28 weeks of gestation and reports of painless vaginal bleeding
Correct Answer: D
Rationale:
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A nurse receives report about assigned clients at the start of the shift. Which of the following clients should the nurse plan to see first?
- A. A client who experienced a cesarean birth 4 hours ago and reports pain
- B. A client who has preeclampsia with a BP of 138/90 mm Hg
- C. A client who experienced a vaginal birth 24 hours ago and reports no bleeding
- D. A client who is scheduled for discharge following a laparoscopic tubal ligation
Correct Answer: A
Rationale: The nurse should prioritize seeing the client who experienced a cesarean birth 4 hours ago and reports pain first. Pain assessment and management are crucial post-cesarean birth to ensure the client's comfort and well-being. Immediate attention is needed to address the client's pain and provide appropriate interventions. The other clients may require attention but do not have an immediate postoperative concern like pain following a cesarean birth.
A nurse on the postpartum unit is caring for a group of clients with an assistive personnel (AP). Which of the following tasks should the nurse plan to delegate to the AP?
- A. Provide a sitz bath to a client who has a fourth-degree laceration and is 2 days postpartum.
- B. Observe an area of redness on the breast of a client who is 1 day postpartum.
- C. Monitor vital signs during admission of a client who has gestational hypertension.
- D. Change the perineal pad of a client who just transferred from labor and delivery.
Correct Answer: A
Rationale: Delegating the task of providing a sitz bath to a client with a fourth-degree laceration and who is 2 days postpartum to the assistive personnel (AP) is appropriate. This task involves assisting the client with personal hygiene and comfort measures that can be safely performed by the AP under the supervision and direction of the nurse. Tasks like observing redness on the breast, monitoring vital signs during admission for gestational hypertension, and changing perineal pads may require a higher level of assessment and nursing judgment, making them more appropriate for the nurse to perform.
A client in labor at 40 weeks of gestation has saturated two perineal pads in the past 30 min. The nurse suspects placenta previa. Which of the following is an appropriate nursing action?
- A. Examination to determine cervical status
- B. A magnesium sulfate infusion
- C. Initiation of pushing
- D. Preparation for cesarean birth
Correct Answer: D
Rationale: In the scenario described, the client is experiencing heavy vaginal bleeding, which is concerning for placenta previa. The appropriate nursing action in this situation is to prepare for a cesarean birth. Placenta previa is a condition where the placenta partially or completely covers the cervix, which can lead to life-threatening bleeding during labor. It is crucial to avoid vaginal examinations or initiation of pushing as these actions can exacerbate bleeding. A magnesium sulfate infusion is not indicated in the management of placenta previa. Therefore, the priority intervention is to prepare for a cesarean birth to ensure the safety of the mother and the baby.
A client at 11 weeks of gestation reports slight occasional vaginal bleeding over the past 2 weeks. Following an examination, the provider informs the client that the fetus has died, indicating a:
- A. Incomplete miscarriage
- B. Missed miscarriage
- C. Inevitable miscarriage
- D. Complete miscarriage
Correct Answer: B
Rationale: A missed miscarriage, also known as a silent or delayed miscarriage, occurs when the embryo or fetus has died, but no bleeding or contractions have occurred to expel it from the uterus. In this scenario, the client's experiencing slight occasional vaginal bleeding over the past two weeks indicates a missed miscarriage as the fetus has died, but the body has not recognized the loss or expelled the products of conception.
A client who experienced a cesarean birth due to dysfunctional labor expresses disappointment for not having a natural childbirth. Which response should the nurse make?
- A. Validate the client's feelings by saying, 'It sounds like you are feeling sad that things didn't go as planned.'
- B. Assure the client by stating, 'At least you know you have a healthy baby.'
- C. Encourage the client by suggesting, 'Maybe next time you can have a vaginal delivery.'
- D. Provide information by saying, 'You can resume sexual relations sooner than if you had delivered vaginally.'
Correct Answer: A
Rationale: The correct response is to acknowledge and validate the client's feelings of disappointment. This empathetic approach demonstrates understanding and support for the client's emotional state, fostering a therapeutic nurse-client relationship. Options B, C, and D do not address the client's emotional needs or provide appropriate support in this situation.