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A nurse is assessing a client who is 1 hr postpartum following a vaginal birth. The nurse notes that the client has excessive vaginal bleeding. Which of the following actions should the nurse take first?
- A. Massage the client's fundus.
- B. Administer oxytocin to the client.
- C. Empty the client’s bladder.
- D. Provide oxygen to the client via nonrebreather face mask.
Correct Answer: A
Rationale: The correct action for the nurse to take first in this situation is to massage the client's fundus. This is because excessive vaginal bleeding postpartum can indicate uterine atony, which is the most common cause of postpartum hemorrhage. Massaging the fundus helps stimulate uterine contractions, which will help to control the bleeding. It is important to address this issue promptly to prevent further complications. Administering oxytocin (choice B) can also help with uterine contractions, but massaging the fundus should be done first. Emptying the client's bladder (choice C) can relieve pressure on the uterus, but it is not the priority in this situation. Providing oxygen (choice D) is not necessary unless the client is showing signs of hypoxia, which is not indicated in the scenario.
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A nurse is caring for a client who is receiving an epidural block with an opioid analgesic. The nurse should monitor for which of the following findings as an adverse effect of the medication?
- A. Hyperglycemia
- B. Bilateral crackles
- C. Hypotension
- D. Polyuria
Correct Answer: C
Rationale: The correct answer is C: Hypotension. Opioid analgesics can cause vasodilation, leading to a drop in blood pressure. The nurse should monitor for hypotension as a potential adverse effect, as this can result in dizziness and decreased perfusion. Hyperglycemia (A) is not typically associated with opioid analgesics. Bilateral crackles (B) are more indicative of fluid overload or pulmonary edema. Polyuria (D) is excessive urination and is not a common adverse effect of opioid analgesics.
A nurse is caring for a client who is at 38 weeks of gestation. Which of the following actions should the nurse take prior to applying an external transducer for fetal monitoring?
- A. Determine progression of dilatation and effacement.
- B. Perform Leopold maneuvers.
- C. Complete a sterile speculum exam.
- D. Prepare a Nitrazine paper test.
Correct Answer: B
Rationale: The correct answer is B: Perform Leopold maneuvers. Prior to applying an external transducer for fetal monitoring at 38 weeks of gestation, the nurse should perform Leopold maneuvers to determine the position of the fetus, fetal lie, presentation, and engagement. This helps in locating the fetal back and identifying the optimal placement for the transducer. Progression of dilatation and effacement (choice A) is more relevant for labor assessment. Completing a sterile speculum exam (choice C) is not necessary for fetal monitoring. Preparing a Nitrazine paper test (choice D) is used to assess for rupture of membranes, not for applying an external transducer.
A nurse is caring for a client who is at 36 weeks of gestation and has methicillin-resistant Staphylococcus aureus. Which of the following types of isolation precautions should the nurse initiate?
- A. Droplet
- B. Contact
- C. Protective environment
- D. Airborne
Correct Answer: B
Rationale: The correct answer is B: Contact precautions. Methicillin-resistant Staphylococcus aureus (MRSA) is primarily spread through direct contact with contaminated skin or surfaces. Contact precautions involve wearing gloves and gowns when in contact with the client or the client's environment to prevent the spread of the infection. Droplet precautions are used for infections transmitted through respiratory droplets, such as influenza. Protective environment precautions are for immunocompromised clients. Airborne precautions are for infections transmitted through small droplets that stay in the air for long periods, such as tuberculosis. Therefore, the most appropriate precaution for a client with MRSA at 36 weeks of gestation is contact precautions to prevent transmission of the infection through direct contact.
A nurse is performing an initial assessment of a newborn who was delivered with a nuchal cord. Which of the following clinical findings should the nurse expect?
- A. Telangiectatic nevi
- B. Facial petechiae
- C. Periauricular papillomas
- D. Erythema toxicum
Correct Answer: B
Rationale: The correct answer is B: Facial petechiae. A nuchal cord occurs when the umbilical cord is wrapped around the baby's neck at birth. This can cause pressure on the baby's blood vessels, leading to tiny red or purple spots on the face called petechiae. This finding indicates possible trauma during delivery. Telangiectatic nevi (choice A) are not typically associated with nuchal cords. Periauricular papillomas (choice C) are benign growths near the ear and are unrelated to nuchal cords. Erythema toxicum (choice D) is a common newborn rash that is not specifically linked to nuchal cords.
The nurse is assessing the client 24 hr later. How should the nurse interpret the findings?
- A. Hematuria
- B. Proteinuria 2+
- C. Leukorrhea
- D. Positive clonus
- E. BUN 40 mg/dL
- F. Platelet count 110,000/mm3
Correct Answer:
Rationale: Correct Answer:
Rationale:
- Hematuria and Proteinuria 2+ are signs of potential worsening conditions that the nurse should interpret as concerning findings.
- Positive clonus is a sign of potential improvement, indicating a positive response to treatment.
- Leukorrhea is unrelated to the diagnosis and should not be a focus of interpretation after 24 hours.
- BUN 40 mg/dL and Platelet count 110,000/mm3 are not provided in the question and thus cannot be interpreted.