Nokea
A nurse is assessing a client 2 hours after a vaginal delivery and notes that the client's uterus is boggy and displaced to the right. Which of the following interventions should the nurse perform first?
- A. Assist the client to void
- B. Massage the uterus
- C. Administer oxytocin
- D. Encourage breastfeeding
Correct Answer: A
Rationale: A boggy and displaced uterus is often a sign of bladder distention, which can prevent the uterus from contracting effectively. The priority intervention is to assist the client to void, which will allow the uterus to return to midline and become firm.
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A nurse is caring for a client who is postpartum, has a deep-vein thrombosis, and is receiving heparin therapy via subcutaneous injections. Which of the following actions should the nurse take?
- A. Request a prescription for PRN aspirin from the provider.
- B. Massage the injection site thoroughly following administration.
- C. Instruct the client that they cannot breastfeed while receiving heparin.
- D. Administer the injection in the client's abdomen.
Correct Answer: D
Rationale: The nurse should administer the injection in the abdomen, as this is a common site for subcutaneous heparin administration. Aspirin is contraindicated for clients on heparin due to increased bleeding risk.
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 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 assessing a newborn 1 hour after birth. The newborn has acrocyanosis and a heart rate of 130 beats per minute. Which of the following actions should the nurse take?
- A. Place the newborn under a radiant warmer
- B. Apply oxygen
- C. Swaddle the newborn
- D. Reassess the newborn in 1 hour
Correct Answer: D
Rationale: Acrocyanosis, or bluish discoloration of the hands and feet, is a normal finding in newborns in the first few hours after birth. The nurse should continue to monitor the newborn and reassess after some time.
A nurse is assessing a newborn and notes that the infant has yellow-tinged skin. Which of the following is the priority nursing action?
- A. Assess the infant's bilirubin levels
- B. Initiate phototherapy
- C. Monitor the infant's temperature
- D. Encourage breastfeeding
Correct Answer: A
Rationale: Yellow-tinged skin (jaundice) in a newborn can indicate hyperbilirubinemia. The priority action is to assess the infant's bilirubin levels to determine the severity of the jaundice and the need for further interventions, such as phototherapy.