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Client 2 hours postpartum, vaginal birth, saturated two perineal pads in 30 minutes
A nurse is caring for a client 2 hours after a spontaneous vaginal birth and the client has saturated two perineal pads with blood in a 30-minute period. Which of the following is the priority nursing intervention at this time?
- A. Assist the client on a bedpan to urinate.
- B. Increase the client's fluid intake.
- C. Palpate the client's uterine fundus.
- D. Prepare to administer oxytocic medication.
Correct Answer: C
Rationale: Palpating the uterine fundus assesses for uterine atony, a common cause of postpartum hemorrhage indicated by excessive bleeding.
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1-day-old newborn, indented anterior fontanelle
The nurse notices while holding him upright that a 1-day-old newborn has a significantly indented anterior fontanelle. She immediately brings it to the attention of the physician. What does this finding most likely indicate?
- A. Increased intracranial pressure.
- B. Vernix caseosa.
- C. Dehydration.
- D. Cyanosis.
Correct Answer: C
Rationale: An indented anterior fontanelle most likely indicates dehydration, as fluid loss causes the fontanelle to sink.
Woman received epidural or intrathecal opioids
The main nursing observations of the woman who receives epidural or intrathecal opioids are for all except
- A. delayed respiratory depression.
- B. inability to move lower extremities.
- C. pruritus.
- D. nausea and vomiting.
Correct Answer: A
Rationale: Delayed respiratory depression is not a primary concern with epidural or intrathecal opioids, which have limited systemic effects compared to systemic opioids.
New mother, postpartum period
Choose the sign or symptom that a new mother should be taught to report:
- A. Occasional uterine cramping when the infant nurses.
- B. Descent of the fundus one fingerbreadth each day.
- C. Reappearance of red lochia after it changes to serous.
- D. Oral temperature that is 37.2 C (99 F) in the morning.
Correct Answer: C
Rationale: Reappearance of red lochia after it becomes serous may indicate uterine atony or retained placental fragments, requiring immediate reporting.
Newborn born at 37 weeks, 12 hours old, tachypnea, grunting, nasal flaring, substernal retractions, acrocyanosis
Complete the diagram by dragging from the choices below to specify what condition the newborn is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the newborn's progress.
- A. Initiate phototherapy as prescribed.
- B. Obtain a urine drug screen.
- C. Administer Surfactant as prescribed.
- D. Administer 30 mL of oral glucose water.
- E. Provide Oxygen Therapy as needed
- F. Hypoglycemia.
- G. Respiratory distress syndrome.
Correct Answer: B
Rationale: Respiratory distress syndrome is likely due to respiratory symptoms. Administer surfactant and provide oxygen therapy address lung immaturity and oxygenation. Monitor arterial blood gases and oxygen saturation to assess progress.
Newborns in nursery
A nurse receives handoff report. Which newborn should the nurse assess first?
- A. Glucose reading 58 mg/dL.
- B. Pulse 144 beats/minute.
- C. Respiratory rate 78 breaths/minute.
- D. Temperature 97.7° F (36.5° C).
Correct Answer: C
Rationale: A respiratory rate of 78 breaths/minute indicates tachypnea, suggesting potential respiratory distress, which requires immediate assessment.