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A nurse is caring for a client who delivered by cesarean birth 6 hr ago. The nurse notes a steady trickle of vaginal bleeding that does not stop with fundal massage. Which of the following actions should the nurse take?
- A. Replace the surgical dressing.
- B. Evaluate urinary output.
- C. Apply an ice pack to the incision site.
- D. Administer 500 mL lactated Ringer’s IV bolus.
Correct Answer: D
Rationale: The correct answer is D: Administer 500 mL lactated Ringer’s IV bolus. This action is necessary to address the ongoing vaginal bleeding after cesarean birth, which may indicate hypovolemia or postpartum hemorrhage. Administering IV fluids helps to restore circulating volume and maintain adequate perfusion to prevent further complications.
Replacing the surgical dressing (A) does not address the underlying issue of vaginal bleeding. Evaluating urinary output (B) is important for assessing renal function but is not the priority in this situation. Applying an ice pack to the incision site (C) is not appropriate for treating postpartum bleeding. Administering a lactated Ringer’s IV bolus (D) is the most urgent intervention to manage the ongoing bleeding and prevent further complications.
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A nurse is planning care immediately following birth for a newborn who has a myelomeningocele that is leaking cerebrospinal fluid. Which of the following actions should the nurse include in the plan of care?
- A. Administer broad-spectrum antibiotics.
- B. Monitor the rectal temperature every 4 hr.
- C. Cleanse the site with povidone-iodine.
- D. Prepare for surgical closure after 72 hr.
Correct Answer: A
Rationale: Correct Answer: A. Administer broad-spectrum antibiotics.
Rationale: Administering broad-spectrum antibiotics is essential to prevent infection in the newborn with a leaking myelomeningocele. The exposed spinal cord increases the risk of infection, which can lead to serious complications such as meningitis. Antibiotics can help prevent or treat any potential infections.
Incorrect Choices:
B. Monitoring rectal temperature every 4 hours is not the priority in this situation. Infection prevention and management should take precedence.
C. Cleansing the site with povidone-iodine may not be appropriate as it can be irritating to the exposed spinal cord.
D. Surgical closure after 72 hours may be delayed if there is an infection present. Administering antibiotics is crucial before proceeding with surgical closure.
A nurse is caring for a client who is in labor and reports increasing rectal pressure. They are experiencing contractions 2 to 3 min apart, each lasting 80 to 90 seconds, and a vaginal examination reveals that their cervix is dilated to 9 cm. The nurse should identify that the client is in which of the following phases of labor?
- A. Passive descent
- B. Active
- C. Early
- D. Descent
Correct Answer: B
Rationale: The correct answer is B: Active phase. At 9cm dilation, the client is transitioning from the latent phase to the active phase of the first stage of labor. In the active phase, contractions are stronger and more frequent, leading to increased rectal pressure and cervical dilation. This phase typically ranges from 6-10cm dilation. Passive descent (A) refers to the early phase of labor when the cervix is dilating but contractions are mild. Early phase (C) is characterized by 0-3cm dilation. Descent (D) is not a recognized phase of labor. The client's symptoms align with the characteristics of the active phase, making option B the correct choice.
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.
A nurse is assessing a newborn who is 16 hr old. Which of the following findings should the nurse report to the provider?
- A. Substernal retractions
- B. Acrocyanosis
- C. Overlapping suture lines
- D. Head circumference 33 cm (13 in)
Correct Answer: A
Rationale: The correct answer is A: Substernal retractions. Substernal retractions in a newborn indicate respiratory distress and can be a sign of a serious issue such as respiratory distress syndrome. This finding requires immediate attention from the provider to assess and manage the newborn's respiratory status. Acrocyanosis (B) is a common finding in newborns and is not typically concerning. Overlapping suture lines (C) can be normal in newborns due to molding during birth. A head circumference of 33 cm (13 in) (D) falls within the normal range for a newborn and does not require immediate reporting.
A nurse is assessing a client who gave birth vaginally 12 hr ago and palpates their uterus to the right above the umbilicus. Which of the following interventions should the nurse perform?
- A. Reassess the client in 2 hr.
- B. Administer simethicone.
- C. Assist the client to empty their bladder.
- D. Instruct the client to lie on their right side.
Correct Answer: C
Rationale: The correct answer is C: Assist the client to empty their bladder. Palpating the uterus above the umbilicus 12 hours postpartum indicates uterine displacement due to a full bladder. A distended bladder can displace the uterus, leading to uterine atony and increased risk of postpartum hemorrhage. By assisting the client to empty their bladder, the nurse can help the uterus return to its proper position, reducing the risk of complications. Reassessing the client in 2 hours (A) does not address the immediate issue of bladder distention. Administering simethicone (B) is indicated for gas relief and not related to the palpated uterus. Instructing the client to lie on their right side (D) may be uncomfortable and does not address the underlying bladder distention.