Nokea
An Asian client 's temperature 10 hours after delivery is 100.2°F, but when encouraged she refuses to drink her ice water. Which of the following nursing actions is most appropriate?
- A. Replace the ice water with hot water.
- B. Notify the client 's health care provider.
- C. Reassess the temperature in one half hour.
- D. Remind the client that drinking is very important.
Correct Answer: A
Rationale: Cultural preferences may influence responses to care. In some cultures, hot liquids are preferred, and providing hot water is culturally appropriate.
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What do ineffective parenting practices put the newborn at risk for?
- A. sleeplessness
- B. reflux
- C. lack of attachment
- D. NICU admission
Correct Answer: C
Rationale: Ineffective parenting practices can lead to a lack of emotional bonding and attachment which can impact the child's development.
A Muslim woman requests something to eat after the delivery of her baby. Which of the following meals would be most appropriate for the nurse to give her?
- A. Ham sandwich.
- B. Bacon and eggs.
- C. Spaghetti with sausage.
- D. Chicken and dumplings.
Correct Answer: D
Rationale: In Islam, pork is prohibited. Chicken is a halal option that adheres to dietary restrictions.
What is the nursing intervention for unilateral edema in a lower extremity and a hot, red area on the leg?
- A. Contact the health-care provider.
- B. Explain this is a normal finding.
- C. Massage calf.
- D. Offer pain medication.
Correct Answer: A
Rationale: Unilateral edema and redness in the leg may indicate a deep vein thrombosis (DVT) a condition that requires medical attention.
The nurse is closely monitoring a patient who is postpartum and at risk for PPH. Which assessment finding will cause the nurse to contact the primary care provider immediately?
- A. The uterus is displaced.
- B. The uterine fundus is boggy.
- C. Small clots are expressed with massage.
- D. Peripad weighs 100 g within 15 minutes.
Correct Answer: D
Rationale: The nurse will monitor the amount and characteristics of each patient’s lochia. If bleeding seems excessive, the nurse will weigh peripads to ascertain the amount of blood loss.
What is a risk factor for PPH found in the prenatal record?
- A. primipara
- B. rubella nonimmune
- C. von Willebrand disorder
- D. history of appendectomy
Correct Answer: C
Rationale: Von Willebrand disorder is a bleeding disorder that increases the risk of postpartum hemorrhage due to impaired clotting.