Nokea
A woman has just had a low forceps delivery. For which of the following should the nurse assess the woman during the immediate postpartum period?
- A. Infection.
- B. Bloody urine.
- C. Heavy lochia.
- D. Rectal abrasions.
Correct Answer: C
Rationale: Heavy lochia indicates potential hemorrhage.
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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.
A mother asks the nurse which powder she should purchase to use on the baby's skin. What should the nurse's response be?
- A. Any powder made especially for babies should be fine.
- B. It is recommended that powder not be put on babies.
- C. There is no real difference except that many babies are allergic to cornstarch so it should not be used.
- D. As long as you put it only on the buttocks area
Correct Answer: B
Rationale: Powder use is discouraged due to inhalation risks.
Intermittent positive pressure boots have been ordered for a client who had an emergency cesarean section. Which of the following is the rationale for that order?
- A. Postpartum clients are at high risk for thrombus formation.
- B. Post-cesarean clients are at high risk for fluid volume deficit.
- C. Postpartum clients are at high risk for varicose vein development.
- D. Post-cesarean clients are at high risk for poor milk ejection reflex.
Correct Answer: A
Rationale: Boots reduce thrombosis risk.
Which of the following full-term babies requires immediate intervention?
- A. Baby with seesaw breathing.
- B. Baby with irregular breathing with 10-second apnea spells.
- C. Baby with coordinated thoracic and abdominal breathing.
- D. Baby with respiratory rate of 52.
Correct Answer: A
Rationale: Seesaw breathing indicates diaphragmatic dysfunction and requires urgent evaluation.
A client has been receiving magnesium sulfate for severe preeclampsia for 12 hours. Her reflexes are 0 and her respiratory rate is 10. Which of the following situations could be a precipitating factor in these findings?
- A. Apical heart rate 104 bpm.
- B. Urinary output 240 mL/12 hr.
- C. Blood pressure 160/120.
- D. Temperature 100°F.
Correct Answer: B
Rationale: Decreased urinary output can lead to magnesium toxicity.