Nokea
A nurse is caring for a client who experienced a vaginal delivery 12 hr ago. When palpating the client's abdomen, at which of the following positions should the nurse expect to find the uterine fundus?
- A. At the level of the umbilicus
- B. 2 cm above the umbilicus
- C. One fingerbreadth above the symphysis pubis
- D. To the right of the umbilicus
Correct Answer: C
Rationale: After a vaginal delivery, the uterus typically undergoes involution, which is the process of the uterus returning to its pre-pregnancy size and position. At 12 hours postpartum, the uterine fundus should be palpated approximately one fingerbreadth above the symphysis pubis. This position indicates proper contraction of the uterus and helps prevent postpartum hemorrhage. As time progresses, the uterine fundus will gradually descend back into the pelvis.
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Which nursing action is most appropriate for a newborn experiencing apnea?
- A. Place the newborn in a prone position
- B. Administer oxygen and stimulate the newborn
- C. Place the newborn under a radiant warmer
- D. Initiate chest compressions immediately
Correct Answer: B
Rationale: Administering oxygen and stimulating the newborn resolves apnea episodes.
The nurse is preparing a postpartum client for discharge. What statement indicates the need for further teaching?
- A. I will avoid heavy lifting for at least 6 weeks.
- B. I can resume sexual activity when I stop bleeding.
- C. I should call my doctor if I experience a fever or foul-smelling discharge.
- D. I will schedule my postpartum visit in 6 weeks.
Correct Answer: B
Rationale: Sexual activity should be resumed based on the healthcare provider's recommendation, not just the cessation of bleeding.
LGBTQIA+ families are at higher risk for certain issues more than straight, cisgender parents. What is an example of a vulnerability experienced by LGBTQIA+ families?
- A. increased cases of social exclusion
- B. fewer cases of intimate partner violence
- C. fewer incidents of family trauma
- D. increased cases of social acceptance
Correct Answer: A
Rationale: LGBTQIA+ families often face social exclusion and discrimination, increasing their vulnerability to mental and physical health challenges.
The pediatric nurse is being pulled to the nursery for the day. The census is six neonates. Which 3 neonates are the best client care assignment for the pediatric nurse?? Select all that apply:
- A. An 18-hour post term, breast-fed neonate with jaundice
- B. A 2-day old who has not passed a meconium stool
- C. A recent admission with Apgar score of 8 out of 10
- D. A 1-day-old with caput succedaneum
Correct Answer: A
Rationale: - A. An 18-hour post-term, breast-fed neonate with jaundice would be a good assignment for the pediatric nurse because a neonate with jaundice requires close monitoring of bilirubin levels and feeding patterns. Breastfeeding can also affect jaundice levels, so the nurse can provide education and support to ensure successful breastfeeding and manage jaundice effectively.
A nurse on a postpartum unit is receiving change-of-shift report for four clients. Which of the following.....
- A. A client who gave a birth 1 day ago and needs Rh˳(D) immune globulin.
- B. A client who gave a birth 3 days ago and reports breath fullness.
- C. A client who gave a birth 12 hr. ago and reports and increase in urinary output.
- D. A client who gave a birth 8 hr. ago and is saturating a perineal pad every hour.
Correct Answer: B
Rationale: The client who gave birth 3 days ago and reports breath fullness is showing signs of potential postpartum complications, such as a pulmonary embolism. Pulmonary embolism is a serious condition that can occur postpartum due to blood clot formation. Symptoms like breath fullness, chest pain, and shortness of breath should never be ignored in postpartum clients. This client requires immediate assessment and intervention to prevent further complications. The other options are concerning but do not indicate as urgent of a situation as breath fullness, which could be a life-threatening issue.