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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 is to massage the client's fundus first. This helps to stimulate uterine contractions and control excessive bleeding, preventing postpartum hemorrhage. Massaging the fundus promotes the expulsion of clots and helps the uterus contract, decreasing the risk of further bleeding. Administering oxytocin (choice B) can be done after fundal massage to enhance uterine contractions. Emptying the client's bladder (choice C) can also aid in reducing uterine atony but is not the priority in this situation. Providing oxygen (choice D) is not directly related to controlling postpartum bleeding.
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What is the function of the amniotic fluid during fetal development?
- A. To cushion and protect the fetus from trauma
- B. To provide a medium for fetal movement and growth
- C. To regulate fetal temperature
- D. All of the above
Correct Answer: D
Rationale: Amniotic fluid serves multiple functions including cushioning the fetus allowing movement and regulating temperature. These roles are essential for healthy fetal development.
A nurse is preparing to administer oxytocin to a client who is postpartum. Which of the following findings is an indication for the administration of the medication? (Select all that apply.)
- A. Flaccid uterus
- B. Cervical laceration
- C. Excess vaginal bleeding
- D. Increased afterbirth cramping
Correct Answer: A,C
Rationale: The correct answers are A and C. A flaccid uterus indicates poor uterine tone, which can lead to postpartum hemorrhage. Oxytocin is given to enhance uterine contractions and tone, helping prevent excessive bleeding. Excess vaginal bleeding is also an indication for oxytocin administration as it can help control bleeding by promoting uterine contractions. Choices B, D, and other options are incorrect as they do not directly relate to the need for oxytocin administration in this scenario. Cervical laceration and increased afterbirth cramping may require other interventions, but they do not specifically indicate the need for oxytocin administration to address postpartum bleeding.
A nurse is assessing a client who is in active labor. Which of the following findings should the nurse report to the provider?
- A. Contractions lasting 80 seconds.
- B. Early decelerations in the PHR.
- C. Temperature 37.4° C (99 3* F).
- D. PHR baseline 170/min.
Correct Answer: D
Rationale: A fetal heart rate baseline of 170/min is tachycardic and should be reported to the provider as it may indicate fetal distress.
A nurse is admitting a client to the birthing unit who reports her contractions started 1 hr ago. The nurse determines the client is 80% effaced and 8 cm dilated. The nurse realizes that the client is at risk for which of the following conditions?
- A. Ectopic pregnancy
- B. Hyperemesis gravidarum
- C. Incompetent cervix
- D. Postpartum hemorrhage
Correct Answer: D
Rationale: The correct answer is D: Postpartum hemorrhage. The nurse assessed the client to be 80% effaced and 8 cm dilated, indicating she is in active labor. This client is at risk for postpartum hemorrhage, which is excessive bleeding after childbirth due to the uterus not contracting adequately to control bleeding. The risk is higher in clients who have a rapid labor progression like this client. Ectopic pregnancy (A) is not relevant in this scenario as the client is already in labor. Hyperemesis gravidarum (B) is severe nausea and vomiting during pregnancy, not related to the client's current condition. Incompetent cervix (C) is the premature dilation of the cervix, not applicable at this stage of labor.
What is the recommended amount of weight gain during pregnancy for a woman with a normal BMI?
- A. 10-15 pounds
- B. 20-30 pounds
- C. 30-40 pounds
- D. 40-50 pounds
Correct Answer: B
Rationale: The correct answer is B (20-30 pounds). This range is recommended for pregnant women with a normal BMI to support the health of both the mother and the baby. Gaining too little weight can lead to complications like low birth weight, while gaining too much weight increases the risk of gestational diabetes and high blood pressure. The other choices are incorrect because they either fall below or exceed the recommended weight gain range, which can pose risks to the pregnancy. It is crucial for the mother to maintain a healthy weight gain to ensure a safe and successful pregnancy.