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A nurse is assessing a postpartum person for signs of infection. What is the most concerning finding in the first 24 hours after delivery?
- A. Fever
- B. Redness and swelling at the site
- C. Increased heart rate
- D. Fatigue
Correct Answer: A
Rationale: The correct answer is A: Fever. In the first 24 hours postpartum, fever is the most concerning finding as it can indicate infection, such as endometritis or mastitis. Fever is a common early sign of infection and requires immediate assessment and intervention. Redness and swelling at the site (B) could be normal postpartum findings. Increased heart rate (C) may be a nonspecific response to stress or dehydration. Fatigue (D) is common postpartum but not typically indicative of infection in the first 24 hours. Fever warrants prompt attention due to the risk of serious complications if left untreated.
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How often should the nurse assess the blood pressure, pulse, and respirations of the birthing person during the first hour of the fourth stage of labor?
- A. every 15 minutes
- B. every 30 minutes
- C. not until after the first hour
- D. once, then hourly
Correct Answer: A
Rationale: The correct answer is A: every 15 minutes. During the first hour of the fourth stage of labor, immediate postpartum assessment is crucial to monitor for any signs of complications such as hemorrhage or shock. Assessing vital signs every 15 minutes allows for early detection of any abnormalities and prompt intervention. This frequency ensures close monitoring of the birthing person's condition and helps in early identification of any potential issues. Choices B, C, and D are incorrect because less frequent assessments may delay the identification of complications, potentially leading to serious consequences. Option C, in particular, is dangerous as it suggests delaying assessments when immediate postpartum monitoring is essential.
Organize the developmental stages in the correct order. Put a comma and space between each answer choice (a, b, c, d, etc.)
- A. Zygote
- B. Morula
- C. Blastocyst
- D. Embryo
Correct Answer: B
Rationale: Fetal development progresses through several stages: zygote, morula, blastocyst, embryo, and fetus. Each stage represents a critical phase in the formation and growth of the embryo.
A 36-week gestation gravid client is complaining of dyspnea when lying flat.
- A. Maternal hypertension.
- B. Fundal height.
- C. Hydramnios.
- D. Congestive heart failure.
Correct Answer: B
Rationale: As the uterus grows, the fundal height increases, which can press on the diaphragm and lead to shortness of breath when lying flat.
A nurse is educating a postpartum person about newborn care. Which of the following should be included in the teaching about umbilical cord care?
- A. keep the cord dry and clean
- B. apply a sterile dressing to the cord
- C. use alcohol or iodine to clean the cord
- D. apply a sterile dressing to the umbilicus
Correct Answer: A
Rationale: The correct answer is A: keep the cord dry and clean. This is because keeping the umbilical cord dry and clean helps prevent infection and promotes healing. Applying a sterile dressing (B) is unnecessary and may trap moisture, leading to infection. Using alcohol or iodine (C) is outdated and can delay cord separation. Applying a sterile dressing to the umbilicus (D) is not recommended as it can interfere with air circulation and healing. In summary, choice A is correct as it aligns with current best practices for umbilical cord care.
The nurse is caring for a pregnant patient who is complaining of frequent heartburn. Which of the following suggestions would be most helpful for managing heartburn during pregnancy?
- A. Lie down immediately after meals to help with digestion.
- B. Eat smaller meals more frequently throughout the day.
- C. Drink large amounts of water after meals to dilute stomach acid.
- D. Increase intake of spicy foods to stimulate digestion.
Correct Answer: B
Rationale: The correct answer is B: Eat smaller meals more frequently throughout the day. This suggestion helps manage heartburn during pregnancy by preventing large meals that can put pressure on the stomach and lead to acid reflux. Eating smaller, more frequent meals helps maintain stable digestion and minimizes the likelihood of triggering heartburn episodes.
A: Lie down immediately after meals is incorrect because it can worsen heartburn by allowing stomach acid to flow back into the esophagus.
C: Drinking large amounts of water after meals can dilute stomach acid, but it may also distend the stomach and exacerbate heartburn symptoms.
D: Increasing intake of spicy foods can aggravate heartburn due to the potential for irritating the stomach lining and increasing acid production.