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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 that can occur postpartum. Uterine tenderness is a common finding in clients with endometritis due to inflammation and infection. A: A temperature of 37.4°C (99.3°F) is within normal range and may not specifically indicate endometritis. B: A WBC count of 9,000/mm3 is also within normal limits and may not be specific to endometritis. D: Scant lochia may be seen in clients with endometritis, but it is not a defining characteristic.
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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: Correct Answer: C. Anticipate a prescription for misoprostol.
Rationale: Misoprostol is a medication that helps to induce uterine contractions, which can help control postpartum bleeding due to uterine atony. It is a common pharmacological intervention for this situation.
Incorrect Choices:
A: Administering betamethasone IM is not indicated for postpartum hemorrhage due to uterine atony. This medication is typically used for fetal lung maturation in preterm labor.
B: Avoiding performing sterile vaginal examinations does not address the primary concern of uterine atony and postpartum bleeding. Assessing the uterus and bleeding are crucial in this situation.
D: Obtaining a specimen for a Kleihauer-Betke test is used to determine the amount of fetal-maternal hemorrhage in Rh-negative women. While important in some situations, it is not the priority in managing postpartum hemorrhage.
The nurse is teaching the client about postpartum depression. The nurse should encourage the client to----------------- and ----------------- to help prevent postpartum depression.
- A. Engage in regular physical activity
- B. Maintain a strong support system
- C. Get adequate rest and sleep
- D. Eat a well-balanced diet
- E. exercise 30 min per day
Correct Answer: B,E
Rationale: The correct answers are B and E. Maintaining a strong support system is crucial in preventing postpartum depression as it provides emotional support. Exercise for 30 minutes per day can help release endorphins, reduce stress, and improve mood. Engaging in regular physical activity (choice A) is beneficial but not as specific as the 30-minute exercise recommendation. Getting adequate rest and sleep (choice C) is important but may not solely prevent postpartum depression. Eating a well-balanced diet (choice D) is essential for overall health but does not directly address the prevention of postpartum depression.
A nurse is reviewing laboratory findings for a client who is at 20 weeks of gestation. Which of the following findings should the nurse report to the provider?
- A. Hematocrit 37% (37% to 47%)
- B. Creatinine 0.9 mg/dL (0.5 to 1 mg/dL)
- C. WBC count 11,000/mm3 (5,000 to 10,000/mm3)
- D. Fasting blood glucose 180 mg/dL (74 to 106 mg/dL)
Correct Answer: D
Rationale: The correct answer is D: Fasting blood glucose 180 mg/dL (74 to 106 mg/dL). At 20 weeks of gestation, elevated blood glucose levels can indicate gestational diabetes, posing risks for both the mother and fetus. The normal range for fasting blood glucose is 74 to 106 mg/dL, so a value of 180 mg/dL is significantly high. The nurse should report this finding to the provider promptly for further evaluation and management to prevent complications.
A: Hematocrit of 37% is within the normal range for pregnancy.
B: Creatinine level of 0.9 mg/dL falls within the normal range.
C: WBC count of 11,000/mm3 is slightly elevated but can be attributed to the normal physiological changes in pregnancy, such as increased demand on the immune system.
Therefore, choices A, B, and C are not significantly concerning at this stage of gestation compared to the high blood glucose
A nurse is assisting the provider to administer a dinoprostone insert to induce labor for a client. Which of the following actions should the nurse take?
- A. Allow the medication to reach room temperature prior to administration.
- B. Place the client in a semi-Fowler’s position for 1 hr after administration.
- C. Instruct the client to avoid urinary elimination until after administration.
- D. Verify that informed consent is obtained prior to administration.
Correct Answer: D
Rationale: The correct answer is D: Verify that informed consent is obtained prior to administration. This is crucial because dinoprostone is a medication used to induce labor, which carries risks and requires informed consent. Without informed consent, the client may not fully understand the potential risks and benefits of the medication.
Choice A is incorrect because room temperature is not a specific requirement for administering dinoprostone. Choice B is incorrect as there is no evidence to support placing the client in a semi-Fowler's position after administration. Choice C is incorrect as avoiding urinary elimination is not necessary for this medication.
In summary, obtaining informed consent is the most important action to ensure the client understands the implications of the medication, making choice D the correct answer.
A nurse is reviewing the chart of a client who is 2 days postpartum following a vaginal delivery and reports constipation. Which of the following findings should the nurse identify as a contraindication to the use of a suppository?
- A. Vaginal candidiasis
- B. Abdominal distention
- C. Afterpains
- D. Third-degree perineal laceration
Correct Answer: D
Rationale: The correct answer is D: Third-degree perineal laceration. Using a suppository in a client with a third-degree perineal laceration can increase the risk of infection or further trauma to the area. It is crucial to allow the laceration to heal properly without introducing any foreign substances.
A: Vaginal candidiasis - This is not a contraindication to using a suppository for constipation.
B: Abdominal distention - This is not a contraindication to using a suppository for constipation.
C: Afterpains - This is not a contraindication to using a suppository for constipation.
In summary, the other choices do not directly impact the safety or effectiveness of using a suppository for constipation postpartum, making them incorrect options.