Nokea
A nurse on a postpartum unit is receiving change-of-shift report for four clients. Which of the following clients should the nurse see first?
- A. A client who gave birth 1 day ago and needs Rho(D) immune globulin
- B. A client who gave birth 3 days ago and reports breast fullness
- C. A client who gave birth 12 hr ago and reports an increase in urinary output
- D. A client who gave birth 8 hr ago and is saturating a perineal pad every hour
Correct Answer: D
Rationale: The client saturating a perineal pad every hour may be experiencing postpartum hemorrhage, which is a medical emergency requiring immediate assessment and intervention.
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A nurse is teaching a client who is to start using a diaphragm for contraception. Which of the following client statements indicate an understanding of the teaching?
- A. I will leave the diaphragm in place for 4 hours following intercourse.
- B. I will remove the diaphragm by catching the rim below the dome with my finger.
- C. I will place a thin layer of mineral oil on the diaphragm once per week.
- D. I will place 2 teaspoons of spermicide on the inside of the diaphragm before inserting it.
Correct Answer: D
Rationale: The client should place spermicide in the diaphragm before insertion to enhance contraceptive effectiveness. The diaphragm should also be left in place for at least 6 hours after intercourse, but not more than 24 hours.
A nurse is assessing a client who gave birth 12 hr ago and is experiencing excessive vaginal bleeding. Which of the following findings indicates the client is experiencing decreased cardiac output?
- A. Bradycardia
- B. Flushed face
- C. Hypotension
- D. Polyuria
Correct Answer: C
Rationale: Hypotension is a key indicator of decreased cardiac output, especially in the context of postpartum hemorrhage, which can lead to significant fluid volume loss and compromise perfusion.
A nurse is caring for a client who is in active labor. The nurse notes early decelerations in the FHR on the fetal monitor tracing. The nurse should identify that which of the following conditions causes early decelerations in the FHR?
- A. Fetal hypoxemia
- B. Cord compression
- C. Uteroplacental insufficiency
- D. Head compression
Correct Answer: D
Rationale: Early decelerations are typically caused by head compression during contractions, which is a normal response and often indicates that the fetus is descending into the birth canal.
A client is in active labor and is receiving an epidural for pain relief. Which of the following should the nurse monitor as the priority?
- A. Fetal heart rate
- B. Client's blood pressure
- C. Client's respiratory rate
- D. Client's pain level
Correct Answer: B
Rationale: The most common side effect of an epidural is hypotension, which can compromise placental perfusion. Monitoring the client's blood pressure is the priority to ensure maternal and fetal well-being.
A nurse is caring for a newborn who has respiratory distress. Which of the following actions should the nurse take first?
- A. Administer oxygen via nasal cannula
- B. Place the newborn in a prone position
- C. Suction the newborn's airway
- D. Notify the healthcare provider
Correct Answer: C
Rationale: In cases of respiratory distress, the nurse should first suction the newborn's airway to clear any obstructions. This is a non-invasive procedure that can quickly improve breathing.