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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: Correct Answer: C. Anticipate a prescription for misoprostol.
Rationale: Misoprostol is a medication that helps to induce uterine contractions, which can help control postpartum bleeding due to uterine atony. It is a common pharmacological intervention for this situation.
Incorrect Choices:
A: Administering betamethasone IM is not indicated for postpartum hemorrhage due to uterine atony. This medication is typically used for fetal lung maturation in preterm labor.
B: Avoiding performing sterile vaginal examinations does not address the primary concern of uterine atony and postpartum bleeding. Assessing the uterus and bleeding are crucial in this situation.
D: Obtaining a specimen for a Kleihauer-Betke test is used to determine the amount of fetal-maternal hemorrhage in Rh-negative women. While important in some situations, it is not the priority in managing postpartum hemorrhage.
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A nurse is collecting data from a client who is at 30 weeks of gestation. Which of the following findings should the nurse identify as a manifestation of pyelonephritis?
- A. Epigastric discomfort
- B. Flank pain
- C. Temperature 37.7°C (99.8°F)
- D. Abdominal cramping
Correct Answer: B
Rationale: The correct answer is B: Flank pain. Pyelonephritis is a kidney infection commonly characterized by flank pain, which is a key symptom. Flank pain is typically located on the side of the body between the upper abdomen and the back. This pain occurs due to inflammation of the kidney tissues. The other choices are incorrect because: A) Epigastric discomfort is more indicative of issues related to the upper abdomen, such as gastritis or pancreatitis. C) A temperature of 37.7°C (99.8°F) is slightly elevated but not specific to pyelonephritis. D) Abdominal cramping is more suggestive of gastrointestinal issues like gas or constipation. Therefore, the presence of flank pain is the most relevant finding to identify pyelonephritis in a client at 30 weeks of gestation.
A nurse is caring for a client who is 1 day postpartum and breastfeeding her newborn. The client reports sore nipples. Which of the following actions should the nurse take?
- A. Instruct the client to wait 4 hr between daytime feedings.
- B. Assess the newborn's latch while breastfeeding.
- C. Have the client limit the length of breastfeeding to 5 min per breast.
- D. Offer supplemental formula between the newborn's feedings.
Correct Answer: B
Rationale: The correct answer is B: Assess the newborn's latch while breastfeeding. Sore nipples in breastfeeding mothers are often caused by improper latch. By assessing the newborn's latch, the nurse can identify any issues and provide guidance to the client on how to improve latch technique, which can alleviate nipple soreness. Waiting 4 hours between feedings (choice A) can lead to engorgement and decreased milk supply. Limiting breastfeeding time to 5 min per breast (choice C) can also affect milk supply. Offering supplemental formula (choice D) can interfere with establishing successful breastfeeding.
A nurse is assessing a client who is 3 days postpartum. Which of the following findings should the nurse report to the provider?
- A. Cool, clammy skin
- B. Moderate lochia serosa
- C. Heart rate 89/min
- D. BP 120/70 mm Hg
Correct Answer: A
Rationale: The correct answer is A: Cool, clammy skin. This finding may indicate hypovolemic shock, a serious condition postpartum. The nurse should report this to the provider immediately for further evaluation and intervention. Choice B, moderate lochia serosa, is a normal finding 3 days postpartum. Choice C, heart rate 89/min, and choice D, BP 120/70 mm Hg, are within normal ranges for a postpartum client and do not require immediate reporting.
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.
Select the 3 findings that require immediate follow-up.
- A. Lateral deviation of the uterus
- B. Deep tendon reflexes 1+
- C. Pain rating of 3 on a scale of 0 to 10 (increased)
- D. Peripheral edema 2+ bilateral lower extremities
- E. Uterine tone soft
- F. Large amount of lochia rubra
- G. Blood pressure 136/86 mm Hg
Correct Answer: A,B,C
Rationale: The correct choices for immediate follow-up are A, B, and C. A lateral deviation of the uterus could indicate a possible complication like uterine atony or retained products of conception. Deep tendon reflexes of 1+ could suggest hyporeflexia or neurological issues. A pain rating of 3 on a scale of 0 to 10, especially if it has increased, may indicate worsening pain or a new issue. Choices D, E, F, and G do not present immediate concerns that require urgent follow-up compared to choices A, B, and C. Peripheral edema 2+ in bilateral lower extremities, soft uterine tone, large amount of lochia rubra, and a blood pressure of 136/86 mm Hg are important findings but do not necessitate immediate intervention or follow-up.