Nokea
A nurse is caring for a client who is 8 hours postpartum following a vaginal birth. The client reports passing large clots and heavy bleeding. Which of the following actions should the nurse take?
- A. Massage the fundus
- B. Administer methylergonovine
- C. Increase the IV fluid rate
- D. Notify the healthcare provider
Correct Answer: A
Rationale: Heavy bleeding and the passage of large clots after childbirth can indicate uterine atony. The nurse should first attempt to massage the fundus to stimulate uterine contractions and control the bleeding.
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Which of the following characteristics would indicate true labor in a client?
- A. Contractions are irregular and painless
- B. Fetus moves to an anterior position
- C. Bloody show is not present
- D. Contractions are regular in frequency
Correct Answer: D
Rationale: True labor is characterized by regular contractions that increase in intensity and frequency. These contractions result in cervical dilation and effacement, indicating the onset of labor.
A nurse is assessing a client who is at 31 weeks of gestation. Which of the following findings should the nurse identify as an indication of a potential prenatal complication?
- A. Periodic tingling of fingers
- B. Absence of clonus
- C. Leg cramps
- D. Blurred vision
Correct Answer: D
Rationale: Blurred vision can be an indicator of serious conditions such as preeclampsia, which involves hypertension and can lead to significant maternal and fetal complications.
A nurse is assessing a newborn who is 48 hr old and has a maternal history of methadone use during pregnancy. Which of the following manifestations should the nurse identify as an indication of neonatal abstinence syndrome?
- A. Hyporeactivity
- B. Excessive high-pitched cry
- C. Acrocyanosis
- D. Respiratory rate of 50/min
Correct Answer: B
Rationale: An excessive high-pitched cry is a classic sign of neonatal abstinence syndrome, indicating withdrawal from substances such as methadone. Other signs may include irritability and tremors.
Following delivery, the nurse places the newborn under a radiant heat warmer. Which of the following is this action used to prevent?
- A. Cold stress
- B. Hyperthermia
- C. Dehydration
- D. Hypoxia
Correct Answer: A
Rationale: Cold stress in newborns can lead to increased oxygen consumption and energy expenditure as the body tries to maintain its temperature. This can result in hypoglycemia and metabolic acidosis if not addressed. The use of a radiant warmer helps maintain the infant's body temperature, reducing the risk of cold stress and its complications.
A nurse is conducting an infertility assessment for a newly admitted client. Which of the following factors should the nurse identify as affecting the client's fertility?
- A. Premature ovarian failure
- B. Renal calculi
- C. Dysmenorrhea
- D. Recurrent urinary tract infection
Correct Answer: A
Rationale: Premature ovarian failure affects fertility by leading to reduced or absent ovarian function, resulting in decreased estrogen production and irregular menstrual cycles.