Nokea
A nurse is assessing a 1-day postpartum client who had a spontaneous vaginal delivery over an intact perineum. The fundus is firm at the umbilicus, lochia moderate, and perineum edematous. One hour after receiving ibuprofen 600 mg po, the client is complaining of perineal pain at level 9 on a 10-point scale. Based on this information, which of the following is an appropriate conclusion for the nurse to make about the client?
- A. She should be assessed by her doctor.
- B. She should have a sitz bath.
- C. She may have a hidden laceration.
- D. She needs a narcotic analgesic.
Correct Answer: C
Rationale: Hidden lacerations can cause severe pain.
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The pediatrician has ordered vitamin K 0.5 mg IM for a newborn. The medication is available as 2 mg/mL. How many milliliters (mL) should the nurse administer to the baby? Calculate to the nearest hundredth.
- A. 0.25 mL
- B. 0.50 mL
- C. 1.00 mL
- D. 2.00 mL
Correct Answer: A
Rationale: Calculation: 0.5 mg ÷ 2 mg/mL = 0.25 mL.
A client just delivered the placenta pictured below. The nurse will document that the woman delivered which of following placentas?
- A. Circumvallate placenta.
- B. Succenturiate placenta.
- C. Placenta with velamentous cord insertion.
- D. Battledore placenta.
Correct Answer: B
Rationale: Succenturiate placenta has accessory lobes.
The nurse includes the addition of ice sitz baths for the postpartum patient. Which assessment finding indicates the treatment has been effective?
- A. No swelling or edema to the perineal area
- B. Patient complains that the sitz bath is too col
- C. Patient reports she took two sitz baths in 12 hours.
- D. Edges of the perineal laceration are well approximate
Correct Answer: A
Rationale: The correct answer is A because the absence of swelling or edema to the perineal area indicates that the ice sitz baths have been effective in reducing inflammation and promoting healing. Swelling and edema are common postpartum, and the use of ice sitz baths can help reduce these symptoms.
Choice B is incorrect because the patient complaining that the sitz bath is too cold does not provide information on the effectiveness of the treatment, only the patient's comfort level.
Choice C is incorrect because the frequency of sitz baths does not necessarily indicate effectiveness. It is more important to assess the outcomes of the treatment rather than the number of baths taken.
Choice D is incorrect because the approximation of perineal laceration edges may be influenced by other factors such as suturing technique, rather than the effectiveness of the ice sitz baths.
A 2-day-old breastfeeding baby born via normal spontaneous vaginal delivery has just been weighed in the newborn nursery. The nurse determines that the baby has lost 3.5% of the birth weight. Which of the following nursing actions is appropriate?
- A. Do nothing because this is a normal weight loss.
- B. Notify the neonatologist of the significant weight loss.
- C. Advise the mother to bottle feed the baby at the next feed.
- D. Assess the baby for hypoglycemia with a glucose monitor.
Correct Answer: A
Rationale: Weight loss up to 7-10% is considered normal in the first few days due to fluid loss; 3.5% does not warrant immediate intervention.
Which of the following comments suggest that a client whose baby was born with a congenital defect is in the bargaining phase of grief?
- A. I hate myself. I caused my baby to be sick.
- B. I'll take him to a specialist. Then he will get better.
- C. I can't seem to stop crying.
- D. This can't be happening.
Correct Answer: B
Rationale: Bargaining involves attempting to find solutions.