Nokea
A nurse is reviewing the chart of a client who is 2 days postpartum following a vaginal delivery and reports constipation. Which of the following findings should the nurse identify as a contraindication to the use of a suppository?
- A. Vaginal candidiasis
- B. Abdominal distention
- C. Afterpains
- D. Third-degree perineal laceration
Correct Answer: D
Rationale: The correct answer is D: Third-degree perineal laceration. Using a suppository in a client with a third-degree perineal laceration can exacerbate pain, increase the risk of infection, and hinder the healing process. The suppository insertion may disrupt the delicate tissue, leading to further trauma and complications. It is crucial to allow the perineal area to heal properly without additional irritation. Choices A, B, and C are not contraindications to the use of a suppository for constipation in a postpartum client. Vaginal candidiasis, abdominal distention, and afterpains do not directly impact the safety or effectiveness of suppository use in this scenario.
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A nurse is caring for a client who is at 10 weeks of gestation. Which of the following findings should the nurse report to the provider?
- A. Frequent vomiting with weight loss of 3 lb in 1 week
- B. Reports of mood swings
- C. Nosebleeds occurring approximately 3 times per week
- D. Increased vaginal discharge
Correct Answer: A
Rationale: The correct answer is A: Frequent vomiting with weight loss of 3 lb in 1 week. This finding could indicate hyperemesis gravidarum, a severe form of morning sickness that can lead to dehydration and malnutrition, posing risks to both the mother and fetus. Weight loss of 3 lb in 1 week is significant and requires immediate attention from the provider to prevent further complications.
Incorrect Choices:
B: Reports of mood swings - Mood swings are common during pregnancy due to hormonal changes and typically do not pose a direct threat to the health of the mother or fetus.
C: Nosebleeds occurring approximately 3 times per week - While nosebleeds can occur during pregnancy due to increased blood flow, they are usually not concerning unless severe or accompanied by other symptoms.
D: Increased vaginal discharge - Increased vaginal discharge is a normal pregnancy symptom caused by hormonal changes and increased blood flow to the pelvic area. It is not typically a cause for immediate concern unless it is accompanied by other
A nurse is providing discharge instructions about newborn safety to a client who is 2 days postpartum. Which of the following instructions should the nurse include?
- A. Lay the baby on his stomach to nap during the daytime.
- B. Change smoke detector batteries every other year.
- C. Use a car seat when traveling by airplane
- D. Place a plastic waterproof sheet over the crib bedding
Correct Answer: C
Rationale: Using a car seat during air travel ensures the newborn's safety during takeoff, landing, and turbulence.
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 caring for a client who is in labor and receiving oxytocin. Which of the following findings indicates that the nurse should increase the rate of infusion?
- A. Contractions every 5 min that last 30 seconds
- B. Montevideo units consistently 300 mm Hg
- C. Urine output of 20 mL/hr
- D. FHR pattern with absent variability
Correct Answer: A
Rationale: Contractions every 5 minutes lasting 30 seconds are inadequate for labor progression, indicating the need to increase oxytocin infusion to strengthen contractions.
Which of the following is a potential complication of a breech delivery?
- A. Fetal distress
- B. Maternal hemorrhage
- C. Birth trauma
- D. All of the above
Correct Answer: C
Rationale: The correct answer is C: Birth trauma. In a breech delivery, where the baby is positioned feet or buttocks first, there is an increased risk of birth trauma due to potential difficulties in delivering the baby's head, leading to possible injuries such as fractures or nerve damage. Fetal distress and maternal hemorrhage can also occur but are not exclusive complications of breech delivery. Choice D, "All of the above," is incorrect as not all potential complications of a breech delivery are listed.