Nokea
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 hypovolemic shock, a serious postpartum complication. The nurse should report this to the provider immediately for further evaluation and intervention to prevent deterioration. Moderate lochia serosa (B) is expected 3 days postpartum. Heart rate of 89/min (C) and BP of 120/70 mm Hg (D) are within normal range for a postpartum client and do not require immediate reporting.
You may also like to solve these questions
A nurse is caring for a client who reports spontaneous rupture of membranes. The nurse observes fetal bradycardia on the FHR tracing and notices that the umbilical cord is protruding. After calling for assistance and notifying the provider, which of the following actions should the nurse take next?
- A. Perform a vaginal examination by applying upward pressure on the presenting part.
- B. Cover the umbilical cord with a sterile saline-saturated towel.
- C. Administer oxygen via nonrebreather mask at 8 L/min.
- D. Initiate an infusion of IV fluids for the client.
Correct Answer: B
Rationale: The correct answer is B: Cover the umbilical cord with a sterile saline-saturated towel. This action is essential to prevent compression and drying of the umbilical cord, which could lead to fetal hypoxia and compromise fetal circulation. By covering the umbilical cord with a sterile saline-saturated towel, the nurse can protect the cord and maintain fetal perfusion until delivery can be expedited. Performing a vaginal examination (choice A) could further compress the cord and worsen the situation. Administering oxygen (choice C) may be beneficial but is not the priority in this urgent situation. Initiating IV fluids (choice D) is not the immediate priority when fetal bradycardia and umbilical cord prolapse are present.
A nurse is assessing a client who is postpartum and has idiopathic thrombocytopenia purpura (ITP). Which of the following findings should the nurse expect?
- A. Decreased platelet count
- B. Increased erythrocyte sedimentation rate (ESR)
- C. Decreased megakaryocytes
- D. Increased WBC
Correct Answer: A
Rationale: The correct answer is A: Decreased platelet count. In ITP, there is a decrease in the number of platelets, leading to an increased risk of bleeding. Platelets are essential for blood clotting, so a decreased count can result in easy bruising, petechiae, and prolonged bleeding. The other choices are incorrect because in ITP, there is no significant increase in ESR, decrease in megakaryocytes (which are platelet precursors), or increase in WBC count. By understanding the pathophysiology of ITP and its effects on platelets, we can confidently select choice A as the expected finding in this scenario.
A nurse is caring for a client following an amniocentesis at 18 weeks of gestation. Which of the following findings should the nurse report to the provider as a potential complication?
- A. Increased fetal movement
- B. Leakage of fluid from the vagina
- C. Upper abdominal discomfort
- D. Urinary frequency
Correct Answer: B
Rationale: Correct Answer: B - Leakage of fluid from the vagina
Rationale: Following an amniocentesis at 18 weeks of gestation, leakage of fluid from the vagina could indicate a potential complication such as premature rupture of membranes. This complication could lead to preterm labor and pose a risk to both the mother and the fetus.
Summary of Other Choices:
A: Increased fetal movement - Normal fetal movement is expected following an amniocentesis and does not necessarily indicate a complication.
C: Upper abdominal discomfort - Common after an amniocentesis due to the needle insertion but usually resolves without major issues.
D: Urinary frequency - Not directly related to complications following an amniocentesis at 18 weeks gestation.
A nurse is preparing to perform Leopold maneuvers on a client who is at 36 weeks of gestation. Identify the sequence of actions the nurse should take.
- A. Instruct the client to empty their bladder.
- B. Position the client supine with knees flexed and place a small, rolled towel under one of their hips.
- C. Palpate the fetal part positioned in the fundus.
- D. Palpate the fetal parts along both sides of the uterus.
Correct Answer: A, B, C, D
Rationale: The correct sequence for performing Leopold maneuvers is A, B, C, D. Firstly, instructing the client to empty their bladder (A) allows for better visualization and palpation of the fetus. Positioning the client supine with knees flexed and a rolled towel under one hip (B) helps relax the abdomen and facilitate palpation. Palpating the fetal part in the fundus (C) helps determine the fetal presentation and position. Finally, palpating the fetal parts along both sides of the uterus (D) aids in assessing the fetal lie and engagement. Choices E, F, and G are not relevant to the correct sequence of Leopold maneuvers.
A nurse is admitting a client to the labor and delivery unit when the client states, 'My water just broke.' Which of the following interventions is the nurse's priority?
- A. Perform Nitrazine testing.
- B. Assess the fluid.
- C. Check cervical dilation.
- D. Begin FHR monitoring.
Correct Answer: D
Rationale: The correct answer is D: Begin FHR monitoring. This is the priority because the client's water breaking indicates a potential risk to the fetus, such as umbilical cord compression or prolapse. FHR monitoring helps assess fetal well-being and detect any signs of distress. Performing Nitrazine testing (A) and checking cervical dilation (C) can wait until after ensuring fetal safety. Assessing the fluid (B) may provide some information but does not directly address the immediate concern for fetal well-being.