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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.
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A nurse on the obstetric unit is caring for a client who experienced abruptio placentae. The nurse observes petechiae and bleeding around the IV access site. The nurse should recognize that this client is at risk for which of the following complications?
- A. Preeclampsia
- B. Puerperal infection
- C. Anaphylactoid syndrome of pregnancy
- D. Disseminated intravascular coagulation
Correct Answer: D
Rationale: The correct answer is D: Disseminated intravascular coagulation (DIC). Abruptio placentae can lead to DIC due to the release of tissue factor, causing widespread clotting and consumption of clotting factors, leading to bleeding. Petechiae and bleeding around the IV site are signs of DIC. Preeclampsia (choice A) is a condition characterized by hypertension and proteinuria. Puerperal infection (choice B) is an infection that occurs after childbirth. Anaphylactoid syndrome of pregnancy (choice C) is a rare complication associated with amniotic fluid embolism. These complications are not directly related to the signs and symptoms described in the scenario.
A nurse is caring for a client who is postpartum and received methylergonovine. Which of the following findings indicates that the medication was effective?
- A. Increase in lochia.
- B. Report of absent breast pain.
- C. Increase in blood pressure.
- D. Fundus firm to palpation.
Correct Answer: D
Rationale: The correct answer is D: Fundus firm to palpation. Methylergonovine is a medication used to prevent or treat postpartum hemorrhage by promoting uterine contractions. When the fundus is firm to palpation, it indicates that the uterus is contracting effectively, which helps prevent excessive bleeding.
Explanation for incorrect choices:
A: Increase in lochia is not an indicator of methylergonovine effectiveness.
B: Absent breast pain is not related to the effectiveness of methylergonovine.
C: Increase in blood pressure is not a typical response to methylergonovine.
D: Fundus firm to palpation is the correct response.
E-G: No additional choices provided.
A nurse in a provider’s office is caring for a client who is at 34 weeks of gestation and at risk for placental abruption. The nurse should recognize that which of the following is the most common risk factor for abruption?
- A. Cocaine use.
- B. Blunt force trauma.
- C. Hypertension.
- D. Cigarette smoking.
Correct Answer: C
Rationale: The correct answer is C: Hypertension. Hypertension is the most common risk factor for placental abruption due to the increased pressure on the placenta, leading to separation from the uterine wall. Cocaine use (A) and cigarette smoking (D) can also increase the risk but are not as common as hypertension. Blunt force trauma (B) can cause a sudden separation of the placenta but is less common compared to hypertension in a routine prenatal setting.
A nurse is caring for a newborn delivered by vaginal birth with a vacuum assist. The newborn’s mother asks about the swollen area on her son’s head. After palpation to identify that the swelling crosses the suture line, which of the following is an appropriate response by the nurse?
- A. This is a cephalohematoma which can occur spontaneously.
- B. A caput succedaneum will subside in a few days.
- C. Mongolian spots can be found on the skin of many newborns.
- D. This is a telangiectatic nevus and no treatment is needed.
Correct Answer: B
Rationale: The correct answer is B: A caput succedaneum will subside in a few days. A caput succedaneum is a diffuse swelling of the scalp that occurs due to pressure on the baby's head during labor. It typically resolves on its own within a few days. In this scenario, since the swelling crosses the suture line, it is likely a caput succedaneum. Palpation of the swelling helps to differentiate it from cephalohematoma, which is confined by suture lines. Choice A is incorrect because a cephalohematoma is a collection of blood between the periosteum and skull bone, not the same as caput succedaneum. Choices C and D are incorrect as they refer to different conditions unrelated to the swelling on the newborn's head.
A nurse is preparing to assess a newborn who is post-term. Which of the following findings should the nurse expect? (Select all that apply)
- A. Vernix in the folds and creases
- B. Abundant lanugo
- C. Positive Moro reflex
- D. Cracked peeling skin
- E. Short soft fingernails
Correct Answer: A,C,D
Rationale: The correct answers are A, C, and D. A post-term newborn is born after 42 weeks of gestation, which can lead to certain physical characteristics.
A: Vernix in the folds and creases is expected in post-term newborns due to prolonged exposure to amniotic fluid.
C: Positive Moro reflex is expected as it indicates the baby's neurological maturity.
D: Cracked peeling skin is common in post-term newborns due to prolonged exposure to amniotic fluid, leading to dryness.
B: Abundant lanugo is typically seen in premature newborns rather than post-term.
E: Short soft fingernails are not specific to post-term newborns.