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A serum electrolyte report for a client, 1 day post-cesarean delivery for eclampsia, has just been received by the nurse. The client is receiving 5% dextrose in 1/2 normal saline IV at 125 mL/hr and magnesium sulfate 2 G/hr IV via infusion pump. Which of the following values should the nurse report to the surgeon?
- A. Magnesium 7 mg/dL.
- B. Sodium 136 mg/dL.
- C. Potassium 3.0 mg/dL.
- D. Calcium 9 mg/dL.
Correct Answer: A
Rationale: Elevated magnesium levels indicate toxicity.
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A breastfeeding woman, 6 weeks postdelivery, must go into the hospital for a hemorrhoidectomy. Which of the following is the best intervention regarding infant feeding?
- A. Have the woman wean the baby to formula.
- B. Have the baby stay in the hospital room with the mother.
- C. Have the woman pump and dump her milk for two weeks.
- D. Have the baby bottle fed milk that the mother has stored.
Correct Answer: D
Rationale: Stored milk ensures continued breastfeeding.
Postpartal overdistention of the bladder and urinary retention can lead to which complication?
- A. Fever and increased blood pressure
- B. Postpartum hemorrhage and eclampsia
- C. Urinary tract infection and uterine rupture
- D. Postpartum hemorrhage and urinary tract infection
Correct Answer: C
Rationale: Rationale: Postpartal overdistention of the bladder and urinary retention can lead to urinary tract infection and uterine rupture. When the bladder is overdistended, it can cause urinary stasis, leading to bacterial growth and increasing the risk of urinary tract infections. Additionally, the pressure from the distended bladder can impede uterine contractions, potentially causing uterine rupture. Fever and increased blood pressure (Choice A) are not direct complications of bladder overdistention. Postpartum hemorrhage and eclampsia (Choice B) are not typically associated with bladder overdistention. Postpartum hemorrhage and urinary tract infection (Choice D) are not as directly related to the complications of bladder overdistention as urinary tract infection and uterine rupture are.
A client is to receive a blood transfusion after significant blood loss following a placenta previa delivery. Which of the following actions by the nurse is critical prior to starting the infusion? Select all that apply.
- A. Look up the client's blood type in the chart.
- B. Check the client's arm bracelet.
- C. Check the blood type on the infusion bag.
- D. Obtain an infusion bag of dextrose and water.
Correct Answer: B
Rationale: Blood type verification is critical.
A client just delivered the placenta pictured below. The nurse will document that the woman delivered which of following placentas?
- A. Circumvallate placenta.
- B. Succenturiate placenta.
- C. Placenta with velamentous cord insertion.
- D. Battledore placenta.
Correct Answer: B
Rationale: Succenturiate placenta has accessory lobes.
A postpartum patient calls the clinic and reports to the nurse feelings of fatigue, tearfulness, and anxiety. What is the nurse’s most appropriate response at this time?
- A. “When did these symptoms begin?”
- B. “Sounds like normal postpartum depression.”
- C. “Are you having trouble getting enough sleep?”
- D. “Are you able to get out of bed and provide care for your baby?”
Correct Answer: A
Rationale: The correct answer is A: "When did these symptoms begin?" The nurse's response should address the patient's concerns and gather more information to assess the situation accurately. By asking when the symptoms began, the nurse can determine the duration and severity of the symptoms, enabling appropriate intervention.
Choice B is incorrect because assuming the symptoms are due to "normal postpartum depression" without further assessment is premature and may overlook other potential causes. Choice C focuses solely on sleep and may not address the underlying issues causing the patient's symptoms. Choice D assumes the patient's ability to provide care for the baby without first addressing the patient's emotional well-being.