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A nurse is assessing a client who is 6 hr postpartum and has endometritis. Which of the following findings should the nurse expect?
- A. Temperature 37.4°C (99.3°F)
- B. WBC count 9,000/mm3
- C. Uterine tenderness
- D. Scant lochia
Correct Answer: C
Rationale: The correct answer is C: Uterine tenderness. Endometritis is characterized by inflammation of the inner lining of the uterus, which results in uterine tenderness. This finding is significant in postpartum clients as it indicates an infection in the uterus. A: Temperature within normal range is not a specific indicator of endometritis. B: WBC count within normal limits is not a specific indicator of endometritis. D: Scant lochia may be present in postpartum clients without endometritis.
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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: Correct Answer: B - Cover the umbilical cord with a sterile saline-saturated towel.
Rationale: Protruding umbilical cord is a medical emergency that can lead to cord compression and compromise blood flow to the baby, resulting in fetal distress. Covering the cord with a sterile saline-saturated towel helps to prevent cord compression and maintain blood flow until delivery can be expedited. This action ensures the baby continues to receive oxygen and nutrients.
Summary of Incorrect Choices:
A: Performing a vaginal examination could further compress the cord and worsen the situation.
C: Administering oxygen may be beneficial for the mother but does not address the immediate risk to the baby from cord compression.
D: Initiating an IV infusion is important but does not address the urgent need to protect the umbilical cord.
E, F, G: No information provided.
A nurse is assessing a newborn who was born postterm. Which of the following findings should the nurse expect?
- A. Large deposits of subcutaneous fat
- B. Thin covering of fine hair on shoulders and back
- C. Nails extending over tips of fingers
- D. Pale, translucent skin
Correct Answer: C
Rationale: The correct answer is C: Nails extending over tips of fingers. Postterm newborns tend to have longer nails due to the prolonged gestation period. This is because the nails continue to grow during the extra time in the womb. Large deposits of subcutaneous fat (A) are more common in preterm infants. Thin covering of fine hair on shoulders and back (B) is characteristic of lanugo, which is typically shed before birth. Pale, translucent skin (D) is more commonly seen in premature babies.
A nurse is caring for a client who delivered by cesarean birth 6 hr ago. The nurse notes a steady trickle of vaginal bleeding that does not stop with fundal massage. Which of the following actions should the nurse take?
- A. Replace the surgical dressing.
- B. Evaluate urinary output.
- C. Apply an ice pack to the incision site.
- D. Administer 500 mL lactated Ringer’s IV bolus.
Correct Answer: D
Rationale: The correct answer is D: Administer 500 mL lactated Ringer’s IV bolus. This action is appropriate as the client is experiencing postpartum hemorrhage, which can lead to hypovolemic shock. Administering IV fluids helps increase circulating volume and stabilize the client's condition. The other choices are incorrect because: A) Replacing the surgical dressing does not address the underlying issue of hemorrhage. B) Evaluating urinary output is important but not the priority when the client is actively bleeding. C) Applying an ice pack to the incision site is not indicated and may not address the hemorrhage. Overall, choice D is the most crucial intervention to address the immediate concern of postpartum hemorrhage.
A nurse is caring for a newborn who has jaundice and a new prescription for phototherapy. Which of the following actions should the nurse take?
- A. Provide the newborn with 15 mL glucose water after each feeding.
- B. Turn the newborn every 4 hr.
- C. Apply hydrating lotion to the newborn’s skin prior to treatment.
- D. Close the newborn's eyes before applying eyepatches.
Correct Answer: D
Rationale: The correct answer is D: Close the newborn's eyes before applying eyepatches. This is important to prevent damage to the eyes from the bright light used in phototherapy. Infants' eyes are sensitive, and prolonged exposure can lead to eye damage. Option A is incorrect as glucose water is not indicated for jaundice treatment. Option B is incorrect as turning the newborn every 4 hours is not specific to phototherapy treatment. Option C is incorrect as hydrating lotion is not necessary for phototherapy. Therefore, the crucial step of closing the newborn's eyes before applying eyepatches is essential for protecting the eyes during phototherapy.
A nurse is caring for a client who is 48 hr postpartum and has a deep vein thrombosis.
- A. Increased warmth in the extremity
- B. Tachycardia
- C. Leukocytosis
- D. Scant lochia rubra
- E. Decreased extremity edema
Correct Answer:
Rationale: Correct Answer:
Rationale:
1. Increased warmth in the extremity: This is a key finding in deep vein thrombosis indicating inflammation and potential clot progression.
2. Tachycardia: Indicative of the body's response to a clot, signifying a worsening condition.
3. Leukocytosis: Elevated white blood cell count suggests an inflammatory response, further confirming a worsening condition.
Summary:
- Scant lochia rubra: Not directly related to deep vein thrombosis, less relevant in this context.
- Decreased extremity edema: While it could indicate improvement, it is not specific to deep vein thrombosis and may not be a reliable indicator.