Nokea
A nurse massages the atonic uterus of a woman who delivered 1 hour earlier. The nurse identifies the nursing diagnosis: Risk for injury related to uterine atony. Which of the following outcomes indicates that the client's condition has improved?
- A. Moderate lochia flow.
- B. Decreased pain level.
- C. Stable blood pressure.
- D. Fundus above the umbilicus.
Correct Answer: A
Rationale: Improved lochia flow indicates resolution of atony.
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A client has just received Hemabate (carboprost) because of uterine atony not controlled by IV oxytocin. For which of the following side effects of the medication will the nurse monitor this patient? Select one that doesn't apply.
- A. Hyperthermia.
- B. Diarrhea.
- C. Hypotension.
- D. Palpitations.
Correct Answer: B
Rationale: Hemabate can cause hyperthermia, hypotension, and palpitations.
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.
A client who has been diagnosed with deep vein thrombosis has been ordered to receive 12 units heparin/min. The nurse receives a 500-mL bag of D5W with 20,000 units of heparin added from the pharmacy. At what rate in mL/hr should the nurse set the infusion pump? (Calculate to the nearest whole.)
- A. 30
- B. NA
- C. NA
- D. NA
Correct Answer: A
Rationale: Calculation: 12 units × 500 mL ÷ 20,000 units = 30 mL/hr.
Which action should the nurse take in order to provide support and encouragement to the new postpartum patient?
- A. Recount how she solved her own problems.
- B. Correct the new mother at every opportunity.
- C. Praise the mother’s early attempts at infant car
- D. Explain to the new mother that everything will be fine
Correct Answer: C
Rationale: The correct answer is C: Praise the mother’s early attempts at infant care. This choice focuses on positive reinforcement, which can boost the new mother's confidence and encourage her in her new role. By acknowledging and praising her efforts, the nurse can help build the mother's self-esteem and foster a supportive environment.
Choices A and D do not directly provide support and encouragement to the new mother. Recounting how the nurse solved her own problems (Choice A) may come off as self-centered and not helpful to the new mother's situation. Explaining that everything will be fine (Choice D) may minimize the new mother's feelings and concerns.
Choice B, correcting the new mother at every opportunity, is not supportive or encouraging. It can undermine the mother's confidence and create a negative dynamic. It is important for the nurse to focus on positive reinforcement and support to help the new mother navigate the challenges of postpartum care.
Which symptom would the nurse expect to observe in a postpartum client with a vaginal hematoma?
- A. Pain.
- B. Bleeding.
- C. Warmth.
- D. Redness.
Correct Answer: A
Rationale: Pain is a common symptom of a vaginal hematoma.