Nokea
A nurse is assessing a client who is 2 hours postpartum and is receiving oxytocin to control postpartum bleeding. Which of the following findings should the nurse report to the provider?
- A. Blood pressure 80/50 mm Hg
- B. Uterine contractions
- C. Urine output 150 mL in 2 hours
- D. Client reports cramping
Correct Answer: A
Rationale: The correct answer is A: 'Blood pressure 80/50 mm Hg.' Hypotension can be a side effect of oxytocin administration. A blood pressure of 80/50 mm Hg should be reported to the provider. Choice B, 'Uterine contractions,' is an expected finding as oxytocin is used to stimulate uterine contractions. Choice C, 'Urine output 150 mL in 2 hours,' is within the expected range postpartum. Choice D, 'Client reports cramping,' is a common finding due to uterine contractions and is not a cause for concern unless excessive or severe.
You may also like to solve these questions
A client in the first stage of labor is experiencing lower back pain and asks the nurse what can be done to relieve the pain. Which of the following interventions should the nurse suggest?
- A. Perform effleurage on the client's abdomen
- B. Apply counterpressure to the client's sacrum
- C. Provide a back massage with lavender oil
- D. Administer opioid analgesics
Correct Answer: B
Rationale: Applying counterpressure to the sacrum can help alleviate lower back pain during labor by reducing pressure on the nerves. Effleurage on the abdomen, back massage with lavender oil, and administering opioid analgesics are not specifically targeted at relieving lower back pain, making them less effective interventions in this scenario.
A healthcare provider is assessing a client who is at 30 weeks of gestation and is receiving magnesium sulfate for preeclampsia. Which of the following findings indicates magnesium toxicity?
- A. Tachycardia
- B. Hyperreflexia
- C. Respiratory rate of 10/min
- D. Polyuria
Correct Answer: C
Rationale: Corrected Rationale: Magnesium sulfate can cause respiratory depression, leading to a decreased respiratory rate. A respiratory rate of 10/min is abnormally low and indicates magnesium toxicity. Tachycardia (Choice A) is not typically associated with magnesium toxicity. Hyperreflexia (Choice B) is a common sign of magnesium toxicity. Polyuria (Choice D) is not a typical finding of magnesium toxicity.
A nurse is caring for a newborn who has neonatal abstinence syndrome. Which of the following actions should the nurse take?
- A. Swaddle the newborn tightly
- B. Provide frequent tactile stimulation
- C. Position the newborn in a prone position
- D. Offer large feedings every 4 hours
Correct Answer: A
Rationale: The correct action for the nurse to take when caring for a newborn with neonatal abstinence syndrome is to swaddle the newborn tightly. Swaddling helps to provide comfort and reduce irritability in these newborns. Choice B, providing frequent tactile stimulation, may exacerbate the symptoms of neonatal abstinence syndrome by overstimulating the newborn. Choice C, positioning the newborn in a prone position, is not recommended as it increases the risk of sudden infant death syndrome (SIDS). Choice D, offering large feedings every 4 hours, is not appropriate as newborns with neonatal abstinence syndrome may have feeding difficulties and need smaller, more frequent feedings.
A nurse is providing care for a client who is in active labor and receiving oxytocin. Which of the following findings should the nurse report to the provider?
- A. Contraction frequency of 2 minutes
- B. Contraction duration of 90 seconds
- C. Fetal heart rate of 150/min
- D. Urine output of 60 mL/hr
Correct Answer: B
Rationale: A contraction duration of 90 seconds can indicate uterine tachysystole, which may lead to fetal hypoxia. Uterine tachysystole is defined as more than five contractions in 10 minutes, averaged over a 30-minute window. Contractions every 2 minutes (Choice A) may occur in active labor but need to be assessed in conjunction with other factors. A fetal heart rate of 150/min (Choice C) is within the normal range. Urine output of 60 mL/hr (Choice D) is also within the expected range for a client in labor.
A nurse is providing discharge teaching to a client who is postpartum and has an episiotomy. Which of the following statements should the nurse include in the teaching?
- A. Avoid sitting for long periods of time.
- B. Apply a cold pack to the perineal area for the first 24 hours.
- C. Use a sitz bath once per week.
- D. Begin Kegel exercises after the first week.
Correct Answer: B
Rationale: The correct statement to include in the teaching is to apply a cold pack to the perineal area for the first 24 hours. This helps reduce swelling and promote comfort, aiding in the healing process after an episiotomy. Option A is incorrect as it does not provide specific guidance on managing postpartum recovery. Option C is incorrect because using a sitz bath once per week may not be frequent enough for proper wound care. Option D is incorrect because beginning Kegel exercises immediately after delivery can put excessive strain on the perineal area, potentially hindering healing.