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A nurse is assessing a client who is 3 days postpartum. Which of the following findings should the nurse report to the provider?
- A. Cool, clammy skin
- B. Moderate lochia serosa
- C. Heart rate 89/min
- D. BP 120/70 mm Hg
Correct Answer: A
Rationale: The correct answer is A: Cool, clammy skin. This finding could indicate hypovolemia or shock, which are serious postpartum complications. The nurse should report this to the provider immediately for further evaluation and intervention.
Other choices are not as urgent:
B: Moderate lochia serosa is expected 3 days postpartum.
C: Heart rate of 89/min is within normal range for a postpartum client.
D: BP of 120/70 mm Hg is also within normal limits.
Therefore, the nurse should prioritize reporting the cool, clammy skin over the other findings.
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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: The correct interpretation is Hematuria. Hematuria (blood in urine) can be a sign of potential worsening condition, requiring further investigation. Proteinuria 2+, Leukorrhea, Positive clonus, BUN of 40 mg/dL, and Platelet count of 110,000/mm3 are not specifically related to the findings 24 hours later and do not provide direct information on the client's status. Hematuria should be a significant focus for further assessment.
A nurse is caring for a client who is 1 hr postpartum and has uterine atony. The client is exhibiting a large amount of vaginal bleeding. Which of the following actions should the nurse take?
- A. Administer betamethasone IM.
- B. Avoid performing sterile vaginal examinations.
- C. Anticipate a prescription for misoprostol.
- D. Obtain a specimen for a Kleihauer-Betke test.
Correct Answer: C
Rationale: The correct answer is C: Anticipate a prescription for misoprostol. Misoprostol is a medication commonly used to manage postpartum hemorrhage due to uterine atony. It helps to promote uterine contractions and control bleeding. Administering betamethasone (A) is not indicated in this situation as it is a steroid used for fetal lung maturation. Avoiding sterile vaginal examinations (B) may delay the identification of the cause of bleeding. Obtaining a specimen for a Kleihauer-Betke test (D) is used to determine the amount of fetal-maternal hemorrhage and is not the immediate priority in managing uterine atony.
A nurse is caring for a newborn immediately following birth. For which of the following reasons should the nurse delay the instillation of antibiotic ophthalmic ointment?
- A. To allow manifestations of infection to be identified
- B. The newborn weighs less than 2.5 kg (5.5 lb)
- C. The newborn was delivered via cesarean birth
- D. To facilitate bonding between the newborn and parent
Correct Answer: D
Rationale: Rationale: The correct answer is D - To facilitate bonding between the newborn and parent. Instillation of antibiotic ointment can interfere with the bonding process between the newborn and parent, as it may create a barrier between them. Bonding is crucial for establishing a strong emotional connection and attachment between the newborn and parent, which is important for the newborn's overall well-being. Delaying the instillation allows for uninterrupted skin-to-skin contact and bonding. Choices A, B, and C are incorrect because delaying antibiotic ointment instillation does not affect the identification of infection manifestations, the newborn's weight, or the mode of delivery.
A nurse is teaching about car seat safety to the parents of a newborn who was delivered at 38 weeks of gestation. Which of the following statements by a parent indicates an understanding of the teaching?
- A. I can use a sleep sack to keep my baby warm in the car seat.'
- B. My baby will need a car seat challenge test before discharge.'
- C. The car seat should be positioned in the car at a 45-degree angle.'
- D. When my baby is 1 year old, I can turn their car seat facing forward.'
Correct Answer: C
Rationale: The correct answer is C because positioning the car seat at a 45-degree angle is important for newborns to prevent their head from falling forward and potentially obstructing their airway. This angle helps keep the baby safe and secure during the ride.
Choice A is incorrect because using a sleep sack in the car seat can interfere with the harness straps and compromise the baby's safety.
Choice B is incorrect as a car seat challenge test is conducted for preterm infants, not infants born at 38 weeks of gestation.
Choice D is incorrect because it is recommended to keep infants in a rear-facing position until they reach the height or weight limit specified by the car seat manufacturer, typically around 2 years old.
A nurse is caring for a client who is 12 hr postpartum and has a fourth-degree laceration of the perineum. Which of the following actions should the nurse take?
- A. Apply a moist, warm compress to the perineum.
- B. Provide the client with a cool sitz bath.
- C. Administer methylergonovine 0.2 mg IM.
- D. Apply povidone-iodine to the client’s perineum after she voids.
Correct Answer: A
Rationale: The correct answer is A: Apply a moist, warm compress to the perineum. This action helps to reduce pain and swelling, promotes healing, and improves comfort. Moist heat increases blood flow to the area, which can aid in the healing process.
Choice B: Providing a cool sitz bath may provide some relief from discomfort, but warm compresses are more effective for promoting healing in this case.
Choice C: Administering methylergonovine is not indicated for a fourth-degree perineal laceration. This medication is used to prevent or control postpartum hemorrhage.
Choice D: Applying povidone-iodine to the perineum is not recommended as it may cause irritation and delay healing.
In summary, choice A is the most appropriate action as it promotes healing and comfort for the client with a fourth-degree perineal laceration. Choices B, C, and D are not recommended in this situation.