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A nurse is calculating the estimated date of delivery for a client who reports that the first day of her last menstrual period was August 10. Using Nägele’s Rule, which of the following is the client’s estimated date of delivery?
- A. May 13
- B. May 17
- C. May 3
- D. May 20
Correct Answer: B
Rationale: The correct answer is B: May 17. Nägele's Rule involves adding 7 days to the first day of the last menstrual period, subtracting 3 months, and adding 1 year. In this case, August 10 + 7 days = August 17, subtracting 3 months gives May 17. This calculation estimates the date of delivery. Choice A (May 13) is incorrect as it doesn't account for the full calculation process. Choice C (May 3) is incorrect as it doesn't consider adding 7 days. Choice D (May 20) is incorrect as it doesn't involve subtracting 3 months.
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Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
- A. Initiate anticoagulant therapy, Administer an oxytocic medication, Apply ice packs to the breasts.
- B. Engorgement, Urinary tract infection, Deed vein thrombosis
- C. Temperature, Circumference of lower extremities, Integrity of the nipples
Correct Answer:
Rationale: Correct Answer: Action to Take: A, B; Potential Condition: B; Parameter to Monitor: C, E.
Rationale:
1. Potential Condition: Engorgement is a common condition postpartum characterized by breast fullness and tenderness.
2. Actions to Take: Initiate anticoagulant therapy to prevent deep vein thrombosis and administer an oxytocic medication to relieve engorgement.
3. Parameters to Monitor: Circumference of lower extremities (for DVT) and integrity of the nipples (for engorgement). These parameters will help assess the client's progress in managing these conditions effectively.
A nurse is administering a hepatitis B vaccine to a newborn. Which of the following actions should the nurse take?
- A. Administer the injection into the vastus lateralis muscle.
- B. Vigorously massage the site following the injection.
- C. Insert the needle at a 45° angle for injection.
- D. Use a 21-gauge needle for the injection.
Correct Answer: A
Rationale: The correct answer is A: Administer the injection into the vastus lateralis muscle. For newborns, the vastus lateralis muscle is the preferred site for intramuscular injections due to its size and well-developed muscle mass, ensuring proper absorption and minimizing the risk of injury to surrounding structures. Administering the vaccine into this muscle also helps improve vaccine efficacy. Choices B, C, and D are incorrect. Choice B, vigorously massaging the site, can cause discomfort, bruising, and potential tissue damage. Choice C, inserting the needle at a 45° angle, is not recommended for intramuscular injections as the needle should be inserted at a 90° angle to ensure proper delivery into the muscle. Choice D, using a 21-gauge needle, is not specific for newborns and can be too large for their small muscle mass, causing unnecessary pain and potential tissue damage.
Select the 3 findings that require immediate follow-up.
- A. Lateral deviation of the uterus
- B. Deep tendon reflexes 1+
- C. Pain rating of 3 on a scale of 0 to 10 (increased)
- D. Peripheral edema 2+ bilateral lower extremities
- E. Uterine tone soft
- F. Large amount of lochia rubra
- G. Blood pressure 136/86 mm Hg
Correct Answer: A,B,C
Rationale: The correct choices for immediate follow-up are A, B, and C. A lateral deviation of the uterus could indicate a possible complication like uterine atony or retained products of conception. Deep tendon reflexes of 1+ could suggest hyporeflexia or neurological issues. A pain rating of 3 on a scale of 0 to 10, especially if it has increased, may indicate worsening pain or a new issue. Choices D, E, F, and G do not present immediate concerns that require urgent follow-up compared to choices A, B, and C. Peripheral edema 2+ in bilateral lower extremities, soft uterine tone, large amount of lochia rubra, and a blood pressure of 136/86 mm Hg are important findings but do not necessitate immediate intervention or follow-up.
A nurse is caring for a client who is 1 day postpartum and breastfeeding her newborn. The client reports sore nipples. Which of the following actions should the nurse take?
- A. Instruct the client to wait 4 hr between daytime feedings.
- B. Assess the newborn's latch while breastfeeding.
- C. Have the client limit the length of breastfeeding to 5 min per breast.
- D. Offer supplemental formula between the newborn's feedings.
Correct Answer: B
Rationale: The correct answer is B: Assess the newborn's latch while breastfeeding. Sore nipples in breastfeeding mothers are often caused by improper latch. By assessing the newborn's latch, the nurse can identify any issues and provide guidance to the client on how to improve latch technique, which can alleviate nipple soreness. Waiting 4 hours between feedings (choice A) can lead to engorgement and decreased milk supply. Limiting breastfeeding time to 5 min per breast (choice C) can also affect milk supply. Offering supplemental formula (choice D) can interfere with establishing successful breastfeeding.
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.