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A nurse is caring for a client who is 1 hour postpartum and observes a large amount of lochia rubra and several small clots on the client’s perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take?
- A. Notify the client’s provider.
- B. Increase the frequency of fundal massage.
- C. Encourage the client to empty her bladder.
- D. Document the findings and continue to monitor the client.
Correct Answer: D
Rationale: The correct answer is D: Document the findings and continue to monitor the client. At 1 hour postpartum, it is normal to have lochia rubra and small clots as the uterus is contracting to expel the placenta fragments. The firm, midline fundus at the umbilicus indicates proper involution. There is no indication of excessive bleeding or abnormal fundal position, so there is no immediate concern. Therefore, the nurse should document the findings to establish a baseline and continue to monitor the client for any changes.
Choice A is incorrect because there is no indication to notify the provider at this time. Choice B is unnecessary as the fundus is already firm. Choice C is not the priority as the fundus position and consistency are appropriate. Monitoring and documentation are essential in this situation to detect any deviations from normal postpartum progress.
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A nurse is assessing a newborn 1 hour after birth. Which of the following respiratory rates is within the expected reference range for a newborn?
- A. 48/min
- B. 22/min
- C. 100/min
- D. 110/min
Correct Answer: A
Rationale: The correct answer is A: 48/min. The normal respiratory rate for a newborn is typically between 30-60 breaths per minute. Choice A falls within this range, indicating a normal respiratory rate for the newborn. Choices B, C, and D are outside the expected reference range. Choice B (22/min) is too low, while choices C (100/min) and D (110/min) are too high, which could indicate respiratory distress or other underlying issues in the newborn. It is important for the nurse to monitor the newborn closely and further assess if the respiratory rate is outside the normal range.
A nurse is caring for a client who is postpartum and finds the fundus slightly displaced to the right. Based on these findings, which of the following actions should the nurse take?
- A. Encourage the client to move to the left lateral position.
- B. Encourage the client to perform Kegel exercises.
- C. Assist the client to the bathroom to void.
- D. Ask the client to rate her pain.
Correct Answer: C
Rationale: The correct answer is C: Assist the client to the bathroom to void. This action helps to empty the bladder, which can reduce uterine displacement. A full bladder can push the uterus to one side. Moving the client to the left lateral position (choice A) may not address the underlying issue of a full bladder. Kegel exercises (choice B) are not directly related to fundal displacement. Asking the client to rate her pain (choice D) is not relevant to the situation at hand.
A nurse in a prenatal clinic is caring for a client who is suspected of having a hydatidiform mole. Which of the following findings should the nurse expect to observe in this client?
- A. Rapid decline in human chorionic gonadotropin (hCG) levels
- B. Irregular fetal heart rate
- C. Excessive uterine enlargement
- D. Profuse, clear vaginal discharge
Correct Answer: C
Rationale: The correct answer is C: Excessive uterine enlargement. A hydatidiform mole is a gestational trophoblastic disease characterized by abnormal growth of placental tissue in the uterus, leading to excessive uterine enlargement. This condition results in the absence of a viable fetus and can cause symptoms such as vaginal bleeding, severe nausea, and hypertension. The other choices are incorrect because: A) Rapid decline in hCG levels is not a typical finding in a hydatidiform mole, as hCG levels are usually elevated. B) Irregular fetal heart rate is not applicable in this case since there is no viable fetus. D) Profuse, clear vaginal discharge is not a characteristic symptom of a hydatidiform mole. E, F, and G are not provided as options.
A nurse is monitoring a client who is 3 days postpartum and is breastfeeding. The nurse notes that the fundus is three fingerbreadths below the umbilicus, lochia rubra is moderate, and the breasts are full and warm to palpation. Which of the following interpretations of these findings should the nurse make?
- A. Additional interventions not indicated at this time.
- B. Application of a heating pad to the breasts is indicated.
- C. The client should be advised to remove her nursing bra.
- D. The client is exhibiting early indications of mastitis.
Correct Answer: A
Rationale: Rationale: The nurse should interpret the findings as normal for a client 3 days postpartum. The fundus being 3 fingerbreadths below the umbilicus is within the expected range. Moderate lochia rubra is normal postpartum bleeding. Full and warm breasts are expected signs of lactation. Choice A is correct because the findings do not indicate any complications requiring additional interventions at this time. Choices B and C are incorrect as there is no indication for heating pads or bra removal. Choice D is incorrect as there are no signs of mastitis present.
A nurse is caring for a newborn and auscultates an apical heart rate of 130/min. Which of the following actions should the nurse take?
- A. Prepare the newborn for transport to the NICU.
- B. Call the provider to further assess the newborn.
- C. Ask another nurse to verify the heart rate.
- D. Document this as an expected finding.
Correct Answer: D
Rationale: The correct answer is D: Document this as an expected finding. In a newborn, a heart rate of 130/min is within the normal range (120-160/min). The nurse does not need to take any immediate action as this heart rate is considered normal for a newborn. Documenting this finding is important for ongoing assessment and continuity of care.
Choice A is incorrect because there is no indication for transport to the NICU based solely on the heart rate. Choice B is unnecessary as further assessment is not warranted for a normal heart rate. Choice C is not needed as the nurse is capable of accurately assessing the heart rate.