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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 an infection of the uterine lining, which causes inflammation and tenderness in the uterus. This finding is expected in a client with endometritis.
A: Temperature of 37.4°C is within normal range postpartum and not specific to endometritis.
B: WBC count of 9,000/mm3 is within normal range and may not be significantly elevated in endometritis.
D: Scant lochia may not be a specific finding for endometritis as lochia changes can vary postpartum.
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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: Correct Answer: A. Apply a moist, warm compress to the perineum.
Rationale: Applying a moist, warm compress helps reduce pain, swelling, and discomfort in the perineal area postpartum. It promotes healing and provides comfort to the client with a fourth-degree laceration. This action also helps improve circulation to the area, aiding in the healing process.
Incorrect Choices:
B: Providing a cool sitz bath may provide relief for hemorrhoids or perineal discomfort but is not the best option for a fourth-degree laceration. Warm compresses are more suitable in this situation.
C: Administering methylergonovine is used to prevent or treat postpartum hemorrhage, not for perineal lacerations.
D: Applying povidone-iodine after voiding is not recommended as it can be irritating to the wound and delay healing.
A nurse in a family planning clinic is caring for a client who requests an oral contraceptive. Which of the following findings in the client’s history should the nurse recognize as a contraindication to oral contraceptives? (Select all that apply.)
- A. Cholecystitis
- B. Hypertension
- C. Human papillomavirus
- D. Migraine headaches
Correct Answer: A, B, D
Rationale: The correct answer is A, B, D. Cholecystitis is a contraindication due to increased risk of gallbladder disease with oral contraceptives. Hypertension is a contraindication because estrogen in oral contraceptives can worsen hypertension. Migraine headaches with aura are a contraindication due to increased risk of stroke. Human papillomavirus is not a contraindication unless it is accompanied by other conditions.
A nurse is providing teaching to a client who is 2 days postpartum and wants to continue using her diaphragm for contraception. Which of the following instructions should the nurse include?
- A. You should have your provider refit you for a new diaphragm.'
- B. You should use an oil-based vaginal lubricant when inserting your diaphragm.'
- C. You should keep the diaphragm in place for at least 4 hours after intercourse.'
- D. You should store your diaphragm in sterile water after each use.'
Correct Answer: A
Rationale: The correct answer is A: "You should have your provider refit you for a new diaphragm." This is important because postpartum changes in the body can affect the fit of the diaphragm. A refitting ensures proper size and fit for effective contraception. Choice B is incorrect because oil-based lubricants can damage latex diaphragms. Choice C is incorrect as the diaphragm should be kept in place for at least 6-8 hours, not 4 hours, for effective contraception. Choice D is incorrect as diaphragms should be stored dry, not in sterile water, to prevent damage.
A nurse is reviewing the medical record of a newly admitted client who is at 32 weeks of gestation. Which of the following conditions is an indication for fetal assessment using electronic fetal monitoring?
- A. Oligohydramnios
- B. Hyperemesis gravidarum
- C. Leukorrhea
- D. Periodic tingling of the fingers
Correct Answer: A
Rationale: The correct answer is A: Oligohydramnios. Electronic fetal monitoring is used to assess fetal well-being by monitoring the baby's heart rate and uterine contractions. Oligohydramnios, which is low amniotic fluid levels, can indicate fetal distress and compromise, necessitating closer monitoring. Hyperemesis gravidarum (B) is severe nausea and vomiting, not directly related to fetal monitoring. Leukorrhea (C) is normal vaginal discharge during pregnancy and not a reason for fetal monitoring. Periodic tingling of the fingers (D) is unrelated to fetal assessment.
A nurse is developing a plan of care for a newborn who is to undergo phototherapy for hyperbilirubinemia. Which of the following actions should the nurse include in the plan?
- A. Feed the newborn 1 oz of water every 4 hr.
- B. Apply lotion to the newborn's skin three times per day.
- C. Remove all clothing from the newborn except the diaper.
- D. Discontinue therapy if the newborn develops a rash.
Correct Answer: C
Rationale: The correct answer is C: Remove all clothing from the newborn except the diaper. This is important because phototherapy requires direct exposure of the newborn's skin to the light source to effectively reduce bilirubin levels. Clothing can block the light and decrease the effectiveness of the therapy. It is essential to maximize skin exposure during phototherapy.
Choice A is incorrect because feeding water is not directly related to phototherapy for hyperbilirubinemia. Choice B is incorrect as applying lotion can interfere with the effectiveness of the therapy by creating a barrier between the skin and the light source. Choice D is incorrect because a rash is a common side effect of phototherapy and does not necessarily require discontinuation of the therapy.