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 complication postpartum. The nurse should report this to the provider immediately for further assessment and intervention. Choice B, moderate lochia serosa, is a normal finding 3 days postpartum. Choice C, heart rate 89/min, and choice D, BP 120/70 mm Hg, are within normal limits for a postpartum client and do not require immediate reporting.
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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: Oxytocin is administered postpartum to manage uterine atony (flaccid uterus) and control excessive bleeding, which are common indications for its use.
Which of the following is a potential complication of maternal hyperthyroidism during pregnancy?
- A. Preterm labor
- B. Fetal growth restriction
- C. Preterm premature rupture of membranes (PPROM)
- D. All of the above
Correct Answer: D
Rationale: Maternal hyperthyroidism can lead to preterm labor, fetal growth restriction, and PPROM.
A nurse is admitting a client who is 1 week postpartum and reports excessive vaginal bleeding. The nurse speaks a different language than the client. The client's partner and 10-year-old child are accompanying her. Which of the following actions should the nurse take to gather the client's admission data?
- A. Have the client's child translate.
- B. Ask a nursing student who speaks the same language as the client to translate.
- C. Request a female interpreter through the facility
- D. Allow the client's partner to translate.
Correct Answer: C
Rationale: Requesting a female interpreter through the facility ensures accurate and professional communication, respecting the client's privacy and cultural preferences. Using a child or partner to translate is inappropriate and may lead to misunderstandings.
Which of the following is a potential ethical issue related to fetal surgery?
- A. Informed consent
- B. Allocation of resources
- C. End-of-life decision making
- D. All of the above
Correct Answer: A
Rationale: Informed consent is a key ethical issue in fetal surgery, ensuring parents understand the risks and benefits.
A school nurse is providing teaching to an adolescent about levonorgestrel contraception. Which of the following information should the nurse include in the teaching?
- A. You should take the medication within 72 hours following unprotected sexual intercourse.
- B. You should avoid taking this medication if you are on an oral contraceptive.
- C. If you don't start your period within 5 days of taking this medication, you will need a pregnancy test.
- D. One dose of this medication will prevent you from becoming pregnant for 14 days after taking it.
Correct Answer: A
Rationale: Levonorgestrel is an emergency contraceptive that should be taken within 72 hours of unprotected intercourse to be most effective in preventing pregnancy.