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.
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A nurse is providing discharge teaching to a client who is postpartum and had a cesarean birth. Which of the following instructions should the nurse include?
- A. You should avoid lifting anything heavier than your newborn
- B. You should not lift anything heavier than your newborn
- C. You should wait 1 week before driving
- D. You can resume sexual activity in 2 weeks
Correct Answer: B
Rationale: The correct instruction for a client who is postpartum and had a cesarean birth is to not lift anything heavier than her newborn. This precaution is crucial to prevent injury to the healing incision site and allow for proper recovery. Choice A is incorrect as it implies resuming abdominal exercises in 2 weeks, which may strain the incision area. Choice C is incorrect because the client should wait longer than 1 week before driving to ensure they can perform emergency maneuvers if needed. Choice D is incorrect as resuming sexual activity in 2 weeks may put strain on the healing tissues and increase the risk of complications.
A client who is 2 days postpartum and breastfeeding reports nipple soreness. Which of the following instructions should the nurse provide?
- A. Avoid using a breast pump.
- B. Apply breast milk to the nipples after feedings.
- C. Feed the newborn less frequently.
- D. Use a nipple shield during feedings.
Correct Answer: B
Rationale: The correct instruction for the nurse to provide is to advise the client to apply breast milk to the nipples after feedings. Breast milk has healing properties and can help soothe sore nipples. Option A is incorrect because avoiding the use of a breast pump does not directly address nipple soreness. Option C is incorrect as feeding the newborn less frequently can lead to engorgement and further complications. Option D is incorrect as using a nipple shield during feedings may not address the underlying issue of soreness and can sometimes even worsen the situation.
A nurse is assessing a newborn who was delivered 24 hours ago. Which of the following findings should the nurse report to the provider?
- A. Caput succedaneum
- B. Jaundice
- C. Acrocyanosis
- D. Overlapping cranial sutures
Correct Answer: B
Rationale: Jaundice occurring within the first 24 hours of life is a sign of pathological jaundice and should be reported to the provider. Caput succedaneum, acrocyanosis, and overlapping cranial sutures are common findings in newborns and do not necessarily require immediate reporting unless they are severe or indicate other underlying issues.
A client who is breastfeeding is receiving teaching from a nurse. Which of the following instructions should the nurse include?
- A. Breastfeed the newborn every 2 hours
- B. Offer both breasts at each feeding
- C. Supplement feedings with formula at night
- D. Expect the newborn to sleep through the night at 1 month
Correct Answer: B
Rationale: The correct instruction for the nurse to include is to offer both breasts at each feeding. This practice helps ensure the baby receives hindmilk from both breasts, promoting adequate milk intake and stimulating milk production. Option A is incorrect as newborns should be breastfed on demand rather than on a strict schedule. Option C is inappropriate as it can interfere with establishing and maintaining a sufficient milk supply. Option D is inaccurate as newborns typically do not sleep through the night at one month; they need to feed frequently for proper growth and development.
A nurse is providing care to a client who is in active labor. The nurse observes variable decelerations in the fetal heart rate. Which of the following actions should the nurse take first?
- A. Administer oxygen at 10 L/min via face mask
- B. Reposition the client from side to side
- C. Increase the rate of the IV infusion
- D. Notify the provider
Correct Answer: B
Rationale: The correct action the nurse should take first when observing variable decelerations in the fetal heart rate is to reposition the client from side to side. Variable decelerations are often caused by umbilical cord compression, and repositioning the client can relieve pressure on the cord. Administering oxygen, increasing the IV infusion rate, and notifying the provider can be appropriate actions but repositioning the client takes priority in addressing variable decelerations.