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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 persistent vaginal bleeding after cesarean birth, as it could be a sign of postpartum hemorrhage. Administering IV fluids helps to improve circulating volume and maintain adequate perfusion to vital organs. This can help stabilize the client's condition while further assessments and interventions are carried out.
Choice A: Replacing the surgical dressing does not address the underlying cause of the bleeding and is not a priority at this time.
Choice B: Evaluating urinary output is important but not the immediate action needed to address the vaginal bleeding.
Choice C: Applying an ice pack to the incision site is not appropriate for controlling postpartum bleeding.
In summary, administering IV fluids is the priority to address potential postpartum hemorrhage, while the other options do not directly address the urgent issue at hand.
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A nurse is preparing to perform Leopold maneuvers on a client who is at 36 weeks of gestation. Identify the sequence of actions the nurse should take.
- A. Instruct the client to empty their bladder.
- B. Position the client supine with knees flexed and place a small, rolled towel under one of their hips.
- C. Palpate the fetal part positioned in the fundus.
- D. Palpate the fetal parts along both sides of the uterus.
Correct Answer: A, B, C, D
Rationale: The correct order for performing Leopold maneuvers on a client at 36 weeks gestation is A, B, C, D. Firstly, instructing the client to empty their bladder (A) allows for better visualization and palpation of the fetus. Secondly, positioning the client supine with knees flexed and placing a small, rolled towel under one hip (B) helps relax the abdominal muscles and provides easier access to the uterus. Next, palpating the fetal part positioned in the fundus (C) helps determine the fetal presentation and position. Finally, palpating the fetal parts along both sides of the uterus (D) allows for further assessment of the fetal position and presentation. Choices E, F, and G are incorrect as they do not align with the sequential steps required for conducting Leopold maneuvers effectively.
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 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: The correct answer is A: Administer broad-spectrum antibiotics. The leaking cerebrospinal fluid puts the newborn at risk for infection, so administering antibiotics helps prevent infection. Monitoring rectal temperature (B) is not directly related to preventing infection. Cleansing the site with povidone-iodine (C) may not be effective in preventing infection. Preparing for surgical closure after 72 hr (D) is important but addressing the risk of infection with antibiotics is the immediate priority.
A nurse is caring for a client who is at 37 weeks of gestation and is being tested for group B streptococcus ß-hemolytic (GBS). The client is multigravida and multipara with no history of GBS. She asks the nurse why the test was not conducted earlier in her pregnancy. Which of the following is an appropriate response by the nurse?
- A. You didn't report any symptoms of GBS during your pregnancy.'
- B. Your previous deliveries were all negative for GBS.'
- C. There was no indication of GBS in your earlier prenatal testing.'
- D. We need to know if you are positive for GBS at the time of delivery.'
Correct Answer: D
Rationale: Rationale: Answer D is correct because testing for GBS at 37 weeks ensures detection of any recent colonization, which can change rapidly. Testing earlier in pregnancy may not accurately reflect GBS status at the time of delivery. Answers A, B, and C are incorrect because the focus should be on current GBS status, not past symptoms or test results. The nurse should prioritize testing closer to delivery for accurate results.
A nurse is reviewing the medical record of a client who had a vaginal delivery 3 hr ago. Which of the following findings place the client at risk for postpartum hemorrhage? (Select all that apply.)
- A. Labor induction with oxytocin
- B. Newborn weight 2.948 kg (6 lb 8 oz)
- C. Vacuum-assisted delivery
- D. History of uterine atony
- E. History of human papillomavirus
Correct Answer: A,C,D
Rationale: The correct answers are A, C, and D. Labor induction with oxytocin can lead to uterine hyperstimulation, increasing the risk of postpartum hemorrhage. Vacuum-assisted delivery can cause trauma to the birth canal and uterus, also increasing the risk. History of uterine atony indicates a previous inability of the uterus to contract effectively after delivery, predisposing the client to postpartum hemorrhage.
Incorrect answers:
B: Newborn weight is not directly related to the risk of postpartum hemorrhage.
E: History of human papillomavirus does not increase the risk of postpartum hemorrhage.
In summary, choices A, C, and D are directly linked to postpartum hemorrhage risk due to their impact on uterine contraction and trauma during delivery, while choices B and E are not causative factors.