Nokea
A nurse is caring for the following four laboring patients. Which client should the nurse be prepared to monitor closely for signs of postpartum hemorrhage (PPH)? Select one that doesn't apply
- A. G1 P0000, delivered a fetal demise at 29 weeks' gestation.
- B. G2 P1001, prolonged first stage of labor.
- C. G2 P0010, delivered by cesarean section for failure to progress.
- D. G3 P0200, delivered vaginally a 42-week, 2,200-gram neonate.
Correct Answer: D
Rationale: These scenarios increase hemorrhage risk.
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What percentage of weight loss did the baby experience? Calculate to the nearest hundredth.
- A. 5.55%
- B. 7.20%
- C. 6.85%
- D. 6.90%
Correct Answer: B
Rationale: Calculation: (3,278 - 3,042) / 3,278 * 100 = 7.20%
A nurse who is called to a client's room notes that the client's cesarean incision has separated. Which of the following actions is the highest priority for the nurse to perform?
- A. Cover the wound with sterile wet dressings.
- B. Notify the surgeon.
- C. Elevate the head of the client's bed slightly.
- D. Flex the client's knees.
Correct Answer: B
Rationale: Immediate surgical intervention is required for wound separation.
A nurse is providing discharge teaching to the parents of a newborn. Which of the following should be included when teaching the parents how to care for the baby's umbilical cord?
- A. Cleanse it with hydrogen peroxide if it starts to smell.
- B. Remove it with sterile tweezers at one week of age.
- C. Call the doctor if greenish drainage appears.
- D. Cover it with sterile dressings until it falls off.
Correct Answer: C
Rationale: Greenish drainage indicates infection and requires medical attention.
The nurse is teaching a non–breastfeeding patient measure to suppress lactation. Which information should the nurse include in the teaching session? (Select all that apply.)
- A. Avoid massaging the breasts.
- B. Allow warm shower water to run over the breasts.
- C. If the breasts become engorged, pumping is recommended
- D. Ice packs or cabbage leaves can be applied to the breasts to relieve discomfort.
Correct Answer: A
Rationale: The correct answer is A: Avoid massaging the breasts. Massaging the breasts can stimulate milk production and worsen engorgement. Therefore, it is essential to avoid any stimulation to prevent further lactation.
Summary:
- Choice B: Allowing warm shower water to run over the breasts can stimulate milk production, so it should be avoided.
- Choice C: Pumping can also stimulate milk production and should be avoided unless instructed by a healthcare provider.
- Choice D: Ice packs or cabbage leaves can provide relief from discomfort but do not suppress lactation.
The nurse is performing a postpartum assessment on a client who delivered 4 hours ago. The nurse notes a firm uterus at the umbilicus with heavy lochial flow. Which of the following nursing actions is appropriate?
- A. Massage the uterus.
- B. Notify the obstetrician.
- C. Administer an oxytocic as ordered.
- D. Assist the client to the bathroom.
Correct Answer: C
Rationale: Oxytocics help control uterine atony and bleeding.