Nokea
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.
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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.
A nurse in a provider’s office is caring for a client who is at 36 weeks of gestation and scheduled for an amniocentesis. The client asks why she is having an ultrasound prior to the procedure. Which of the following is an appropriate response by the nurse?
- A. It assists in identifying the location of the placenta and fetus.
- B. It is useful for estimating fetal age.
- C. This is a screening tool for spina bifida.
- D. This will determine if there is more than one fetus.
Correct Answer: A
Rationale: Correct Answer: A
Rationale: Prior to amniocentesis, an ultrasound is done to identify the location of the placenta and fetus. This is crucial to ensure the safety of the procedure. It helps in determining the best site for needle insertion to avoid harming the fetus or placenta. Additionally, it allows for visualization of any abnormalities that could affect the amniocentesis procedure.
Summary of other choices:
B: Estimating fetal age is not the primary purpose of the ultrasound before amniocentesis.
C: Screening for spina bifida is usually done through other specific tests, not the ultrasound before amniocentesis.
D: Determining if there is more than one fetus is not the main goal of the ultrasound before amniocentesis.
A male newborn infant has just been circumcised. The nurse checks the surgical site, expecting it to have what appearance?
- A. Reddened with a small amount of bloody drainage.
- B. Pink without drainage.
- C. Reddened with a scant amount of yellow exudate.
- D. Reddened, with copious blood.
Correct Answer: C
Rationale: The correct answer is C: Reddened with a scant amount of yellow exudate. After circumcision, it is normal for the surgical site to appear reddened due to the inflammatory response. The presence of a scant amount of yellow exudate indicates normal wound healing with minimal discharge. This is a sign of the body's natural process of cleansing the wound. Choices A and D are incorrect because copious blood or bloody drainage would be abnormal and may indicate bleeding complications. Choice B is incorrect as pink without drainage would not be expected immediately after circumcision. In choice A, while some bloody drainage may be expected, the presence of yellow exudate is more indicative of normal healing.
A nurse is caring for a client who is 1 hour postpartum and observes a large amount of lochia rubra and several small clots on the client’s perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take?
- A. Notify the client’s provider.
- B. Increase the frequency of fundal massage.
- C. Encourage the client to empty her bladder.
- D. Document the findings and continue to monitor the client.
Correct Answer: D
Rationale: The correct answer is D: Document the findings and continue to monitor the client. At 1 hour postpartum, it is normal to have lochia rubra and small clots as the uterus is contracting to expel the placenta fragments. The firm, midline fundus at the umbilicus indicates proper involution. There is no indication of excessive bleeding or abnormal fundal position, so there is no immediate concern. Therefore, the nurse should document the findings to establish a baseline and continue to monitor the client for any changes.
Choice A is incorrect because there is no indication to notify the provider at this time. Choice B is unnecessary as the fundus is already firm. Choice C is not the priority as the fundus position and consistency are appropriate. Monitoring and documentation are essential in this situation to detect any deviations from normal postpartum progress.
A nurse in the ambulatory surgery center is providing discharge teaching to a client who had a dilation and curettage (D&C) following a spontaneous miscarriage. Which of the following should be included in the teaching?
- A. Products of conception will be present in vaginal bleeding.
- B. Increased intake of zinc-rich foods is recommended.
- C. Vaginal intercourse can be resumed after 2 weeks.
- D. Aspirin may be taken for cramps.
Correct Answer: C
Rationale: The correct answer is C: Vaginal intercourse can be resumed after 2 weeks. This is important to prevent infection and allow the cervix to heal. Choice A is incorrect as products of conception are typically expelled during the D&C procedure. Choice B is irrelevant as zinc intake is not directly related to post-D&C care. Choice D is incorrect as aspirin can increase the risk of bleeding post-D&C.