Nokea
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.
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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.
A nurse administered RhoGAM to a client whose blood type is A+ (positive). Which of the following responses would the nurse expect to see? Select all that apply.
- A. Fever.
- B. Flank pain.
- C. Dark-colored urine.
- D. Swelling at the injection site.
Correct Answer: D
Rationale: Localized swelling and dark urine may occur.
A breastfeeding mother calls the obstetrician's office with a complaint of pain in one breast. Upon inspection, a diagnosis of mastitis is made. Which of the following nursing interventions is appropriate?
- A. Advise the woman to apply ice packs to her breasts.
- B. Encourage the woman to breastfeed frequently.
- C. Inform the woman that she should wean immediately.
- D. Direct the woman to notify her pediatrician as soon as possible.
Correct Answer: B
Rationale: Frequent breastfeeding helps clear infection.
The nurse is providing care to a patient 2 hours after a cesarean birth. In the hand-off report, he preceding nurse indicated that the patient’s lochia was scant rubra. On initial assessment, the oncoming nurse notes the patient’s peripad is saturated with lochia rubra immediately after breastfeeding her infant. What is the nurse’s priority action with this finding?
- A. Weigh the peripad.
- B. Replace the peripad.
- C. Contact the health care provider.
- D. Document the finding in the patient’s chart.
Correct Answer: C
Rationale: The correct answer is C: Contact the health care provider. This is the priority action because the sudden increase in lochia flow after breastfeeding could indicate postpartum hemorrhage, which is a serious complication that requires immediate medical attention. Contacting the healthcare provider will allow for prompt assessment and intervention.
A: Weigh the peripad - This is not the priority action as assessing the amount of blood loss is important, but contacting the healthcare provider for further assessment and intervention takes precedence.
B: Replace the peripad - While maintaining cleanliness and hygiene is important, addressing the potential postpartum hemorrhage is the priority.
D: Document the finding in the patient’s chart - Documentation is necessary but should come after the immediate concern of postpartum hemorrhage is addressed.
A client is 10 minutes postpartum from a forceps delivery of a 4,500-gram neonate with a cleft lip. The physician performed a right mediolateral episiotomy during the delivery. The client is at risk for each of the following nursing diagnoses. Which of the diagnoses is highest priority at this time?
- A. Ineffective breastfeeding.
- B. Fluid volume deficit.
- C. Infection.
- D. Pain.
Correct Answer: D
Rationale: Pain management is critical post-episiotomy.