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A nurse is assessing a client who gave birth vaginally 12 hr ago and palpates their uterus to the right above the umbilicus. Which of the following interventions should the nurse perform?
- A. Reassess the client in 2 hr.
- B. Administer simethicone.
- C. Assist the client to empty their bladder.
- D. Instruct the client to lie on their right side.
Correct Answer: C
Rationale: The correct answer is C: Assist the client to empty their bladder. Palpating the uterus above the umbilicus indicates uterine atony, a common cause of postpartum hemorrhage. A full bladder can displace the uterus further, exacerbating the risk of hemorrhage. Emptying the bladder will allow the uterus to contract properly and reduce the risk. Reassessing the client in 2 hours (A) delays immediate intervention. Administering simethicone (B) is for gas relief and not relevant in this situation. Instructing the client to lie on their right side (D) does not address the underlying issue of uterine atony.
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A nurse is teaching a client who has pregestational type 1 diabetes mellitus about management during pregnancy. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will need to increase my insulin doses during the first trimester.
- B. I should engage in moderate exercise for 30 minutes if my blood glucose is 250 or greater.
- C. I will continue taking my insulin if I experience nausea and vomiting.
- D. I will ensure that my bedtime snack is high in refined sugar.
Correct Answer: C
Rationale: Correct Answer: C - "I will continue taking my insulin if I experience nausea and vomiting."
Rationale: Nausea and vomiting can lead to decreased food intake, which may cause a drop in blood glucose levels. Continuing to take insulin as prescribed is crucial to prevent hypoglycemia and maintain stable blood glucose levels for both the mother and the baby. This demonstrates the client's understanding of the importance of insulin therapy during pregnancy.
Summary of other choices:
A: Increasing insulin doses during the first trimester is not recommended without healthcare provider guidance as insulin needs may vary.
B: Exercising with blood glucose levels of 250 or greater can be dangerous and may lead to further hyperglycemia.
D: Consuming a bedtime snack high in refined sugar can cause blood glucose spikes, which is not recommended for diabetes management during pregnancy.
A nurse is assessing a newborn who is 16 hr old. Which of the following findings should the nurse report to the provider?
- A. Substernal retractions
- B. Acrocyanosis
- C. Overlapping suture lines
- D. Head circumference 33 cm (13 in)
Correct Answer: A
Rationale: The correct answer is A: Substernal retractions. Substernal retractions in a newborn may indicate respiratory distress, which requires immediate attention from the provider to prevent further complications. Acrocyanosis (choice B) is a common finding in newborns and is considered normal. Overlapping suture lines (choice C) can be a result of molding during the birth process and typically resolve on their own. A head circumference of 33 cm (13 in) (choice D) falls within the normal range for a newborn and does not require immediate reporting.
A nurse is teaching about home safety with a client who is 2 days postpartum. Which of the following instructions should the nurse include in the teaching?
- A. Bathe your baby immediately after a feeding.
- B. Place a bumper pad in your baby’s crib.
- C. Put a soft mattress in your baby’s crib.
- D. Wash your baby’s face with plain water.
Correct Answer: D
Rationale: The correct answer is D: Wash your baby's face with plain water. This instruction is important to prevent skin irritation and infection in newborns. Washing the baby's face with plain water helps to keep the delicate skin clean without introducing any harsh chemicals or irritants. It is gentle and safe for the baby's sensitive skin.
Summary of why the other choices are incorrect:
A: Bathing the baby immediately after a feeding can lead to discomfort and potential issues with digestion.
B: Placing a bumper pad in the baby's crib increases the risk of suffocation and Sudden Infant Death Syndrome (SIDS).
C: Putting a soft mattress in the crib can pose a suffocation hazard and increase the risk of SIDS.
E, F, G: No additional choices provided.
A nurse is planning care for a client who is in labor and is to have an amniotomy. Which of the following assessments should the nurse identify as the priority?
- A. O2 saturation
- B. Temperature
- C. Blood pressure
- D. Urinary output
Correct Answer: B
Rationale: The correct answer is B: Temperature. During an amniotomy, there is an increased risk of infection due to the introduction of bacteria into the uterine cavity. Monitoring the client's temperature is crucial to detect any signs of infection promptly. A sudden spike in temperature could indicate chorioamnionitis, a serious infection that can harm both the mother and the baby. O2 saturation (A), blood pressure (C), and urinary output (D) are important assessments but are not the priority in this situation. Monitoring O2 saturation is essential for fetal well-being but is not directly related to the amniotomy procedure. Blood pressure monitoring is significant for detecting any changes in maternal status, but infection assessment takes precedence in this case. Urinary output is essential for assessing hydration status and kidney function, but infection monitoring is more critical during an amniotomy.
A nurse is caring for a client who is in active labor with a fetus in the occipitoposterior position. The nurse assists the client into a hands-and-knees position. Which of the following questions should the nurse ask to evaluate the effectiveness of this intervention?
- A. Does that lessen your suprapubic pain?
- B. Are you feeling relief from your pelvic pressure?
- C. Do your contractions feel further apart?
- D. Has your back labor improved?
Correct Answer: D
Rationale: The correct answer is D: "Has your back labor improved?" This question is crucial because the occipitoposterior position can cause intense back pain during labor. By asking if the back labor has improved, the nurse can assess the effectiveness of the hands-and-knees position in helping relieve the client's discomfort. A: "Does that lessen your suprapubic pain?" is incorrect because suprapubic pain is not specifically associated with occipitoposterior positioning. B: "Are you feeling relief from your pelvic pressure?" is incorrect as it does not directly address the back pain associated with occipitoposterior positioning. C: "Do your contractions feel further apart?" is incorrect as it does not focus on the back pain issue. The key is to address the specific discomfort caused by the occipitoposterior position.