Nokea
A postpartum client's fundus is firm, 3 cm above the umbilicus and displaced to the right. Which of the following interventions should the nurse take?
- A. Massage the fundus
- B. Administer oxytocin
- C. Assist the client to void then reassess the fundus
- D. Notify the healthcare provider
Correct Answer: C
Rationale: Displacement of the uterus from the midline is often a sign of bladder distention. A full bladder can prevent the uterus from contracting properly, which could increase the risk of postpartum hemorrhage. The nurse should assist the client to void and then reassess the position and firmness of the fundus to ensure appropriate uterine contraction.
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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 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.
A nurse has provided education to a client who has been prescribed oral contraception. Which of the following client statements indicates a need for further education?
- A. If I miss one pill, I'll take it as soon as possible
- B. If I miss two pills, I'll double up for two days
- C. If I miss three pills, I'll double up each day until back on schedule
- D. I'll use an alternative form of contraception if I miss more than two pills
Correct Answer: C
Rationale: The correct course of action after missing oral contraceptive pills depends on how many pills are missed. If three pills are missed, the client should not 'double up' but rather follow the manufacturer's instructions and use an alternative form of contraception until the next cycle. Taking too many pills at once increases the risk of side effects without restoring contraceptive protection.
A nurse is caring for a laboring client and notes that the fetal heart rate begins to decelerate after the contraction has started. The lowest point of deceleration occurs after the peak of the contraction. What is the priority nursing action?
- A. Administer oxygen
- B. Change the client's position
- C. Increase IV fluids
- D. Call the healthcare provider
Correct Answer: B
Rationale: Late decelerations are caused by uteroplacental insufficiency, indicating that the fetus is not receiving adequate oxygen during contractions. This is an emergency that requires prompt intervention. Changing the client's position helps to improve placental blood flow, which can reduce the stress on the fetus. If the decelerations continue, further interventions, including oxygen administration and notifying the provider, may be necessary.
A nurse is caring for a client who is experiencing urinary incontinence. Which of the following recommendations should the nurse include in the teaching plan for this client?
- A. Drink large amounts of water before bedtime
- B. Perform Kegel exercises regularly
- C. Limit fiber in the diet to avoid bowel irritation
- D. Increase intake of caffeinated and carbonated beverages
Correct Answer: B
Rationale: Kegel exercises help strengthen the pelvic floor muscles, which can improve bladder control and reduce urinary incontinence. The nurse should instruct the client to practice these exercises regularly.