Nokea
A nurse is caring for a client who is 1 hr postpartum and has uterine atony. The client is exhibiting a large amount of vaginal bleeding. Which of the following actions should the nurse take?
- A. Administer betamethasone IM.
- B. Avoid performing sterile vaginal examinations.
- C. Anticipate a prescription for misoprostol.
- D. Obtain a specimen for a Kleihauer-Betke test.
Correct Answer: C
Rationale: The correct answer is C: Anticipate a prescription for misoprostol. Misoprostol is a medication used to help contract the uterus and control postpartum hemorrhage caused by uterine atony. It helps stimulate uterine contractions and reduce bleeding. Administering betamethasone (choice A) is not indicated for uterine atony and postpartum hemorrhage. Avoiding sterile vaginal examinations (choice B) does not address the underlying issue of uterine atony. Obtaining a specimen for a Kleihauer-Betke test (choice D) is used to assess the amount of fetal-maternal hemorrhage and is not an immediate intervention for uterine atony.
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A nurse is providing teaching for a client who has a new prescription for combined oral contraceptives. Which of the following findings should the nurse include as an adverse effect of this medication?
- A. Depression.
- B. Polyuria.
- C. Hypotension.
- D. Urticaria.
Correct Answer: A
Rationale: Depression is a known adverse effect of combined oral contraceptives due to the hormonal changes they induce.
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, causing inflammation and tenderness. This finding is expected in a client with endometritis. A: A slightly elevated temperature may be present, but it is not specific to endometritis. B: A normal WBC count does not rule out endometritis. D: Scant lochia is not a characteristic finding in endometritis. Other answer choices are not provided, but uterine tenderness is the most relevant symptom in this scenario.
A nurse is assessing a client who is postpartum following a cesarean birth. The client states, 'I feel like I have to urinate but I can’t go.' Which of the following actions should the nurse take?
- A. Assist the client to ambulate to the bathroom
- B. Insert an indwelling urinary catheter
- C. Perform a bladder scan to assess for urinary retention
- D. Administer a diuretic
Correct Answer: A
Rationale: The correct answer is A: Assist the client to ambulate to the bathroom. This action helps in promoting normal voiding patterns post-cesarean birth. Ambulation can aid in relieving pressure on the bladder, stimulating the urge to urinate, and facilitating the flow of urine. It also promotes circulation, which can help in reducing the risk of urinary retention.
Choice B: Inserting an indwelling urinary catheter should not be the initial intervention as it carries a risk of introducing infection and may not be necessary at this point.
Choice C: Performing a bladder scan can be considered if the client is unable to void after ambulation and other interventions have been attempted.
Choice D: Administering a diuretic is not appropriate in this situation as the client is experiencing difficulty in urinating rather than retaining excessive urine.
In summary, assisting the client to ambulate to the bathroom is the most appropriate initial action to address the client's complaint and promote normal voiding.
A nurse is providing teaching to a client who is breastfeeding and experiencing engorgement. Which of the following recommendations should the nurse include?
- A. Apply warm compresses on the breasts before feedings
- B. Allow the infant to nurse on one breast per feeding.
- C. Take aspirin to reduce pain and swelling.
- D. Wear a tight-fitting underwire bra.
Correct Answer: A
Rationale: Warm compresses help to relieve engorgement by promoting milk flow and reducing discomfort before feedings.
What is the recommended method of feeding for a premature infant?
- A. Breastfeeding
- B. Formula feeding
- C. Tube feeding
- D. All of the above
Correct Answer: C
Rationale: Tube feeding is often recommended for premature infants who may not have the ability to suck and swallow effectively. It ensures they receive adequate nutrition.