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During the admission assessment of a client at 38 weeks of gestation with severe preeclampsia, what would the nurse expect as a finding?
- A. Tachycardia
- B. Absence of clonus
- C. Polyuria
- D. Report of headache
Correct Answer: D
Rationale: Severe preeclampsia is characterized by hypertension and proteinuria after 20 weeks of gestation. Headache is a common symptom in clients with severe preeclampsia due to cerebral edema or vasospasm. Tachycardia (Choice A) is not typically associated with severe preeclampsia. Clonus (Choice B) is a sign of hyperactive reflexes, often seen in clients with severe preeclampsia. Polyuria (Choice C) is not a typical finding in clients with severe preeclampsia.
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A nurse receives report about assigned clients at the start of the shift. Which of the following clients should the nurse plan to see first?
- A. A client who experienced a cesarean birth 4 hours ago and reports pain
- B. A client who has preeclampsia with a BP of 138/90 mm Hg
- C. A client who experienced a vaginal birth 24 hours ago and reports no bleeding
- D. A client who is scheduled for discharge following a laparoscopic tubal ligation
Correct Answer: A
Rationale: The nurse should prioritize seeing the client who experienced a cesarean birth 4 hours ago and reports pain first. Pain assessment and management are crucial post-cesarean birth to ensure the client's comfort and well-being. Immediate attention is needed to address the client's pain and provide appropriate interventions. The other clients may require attention but do not have an immediate postoperative concern like pain following a cesarean birth.
A client is being assessed for postpartum infection. Which of the following findings should indicate to the healthcare provider that the client requires further evaluation for endometritis?
- A. Localized area of breast tenderness
- B. Pelvic pain
- C. Vaginal discharge with foul odor
- D. Hematuria
Correct Answer: B
Rationale: Pelvic pain is a common symptom of endometritis, which is an infection of the uterine lining. It is an important finding that warrants further evaluation. Localized area of breast tenderness may indicate mastitis, vaginal discharge with a foul odor could suggest a vaginal infection, and hematuria points towards a urinary tract issue, but they are not specific to endometritis.
A nurse on the postpartum unit is caring for a group of clients with an assistive personnel (AP). Which of the following tasks should the nurse plan to delegate to the AP?
- A. Provide a sitz bath to a client who has a fourth-degree laceration and is 2 days postpartum.
- B. Observe an area of redness on the breast of a client who is 1 day postpartum.
- C. Monitor vital signs during admission of a client who has gestational hypertension.
- D. Change the perineal pad of a client who just transferred from labor and delivery.
Correct Answer: A
Rationale: Delegating the task of providing a sitz bath to a client with a fourth-degree laceration and who is 2 days postpartum to the assistive personnel (AP) is appropriate. This task involves assisting the client with personal hygiene and comfort measures that can be safely performed by the AP under the supervision and direction of the nurse. Tasks like observing redness on the breast, monitoring vital signs during admission for gestational hypertension, and changing perineal pads may require a higher level of assessment and nursing judgment, making them more appropriate for the nurse to perform.
A client who is 4 hours postpartum following a vaginal delivery is being assessed by a nurse. Which of the following findings should the nurse identify as the priority?
- A. Saturated perineal pad in 30 minutes
- B. Deep tendon reflexes 4+
- C. Fundus at the level of the umbilicus
- D. Approximated edges of episiotomy
Correct Answer: A
Rationale: In a client who is 4 hours postpartum, a saturated perineal pad within 30 minutes is a priority finding as it may indicate excessive postpartum bleeding (hemorrhage), which requires immediate intervention to prevent further complications such as hypovolemic shock. Deep tendon reflexes being 4+ is within normal limits postpartum. The fundus at the level of the umbilicus is an expected finding at this time frame, indicating proper involution of the uterus. Approximated edges of an episiotomy suggest proper healing.
A client with preterm labor is being admitted. The nurse anticipates a prescription by the provider for which of the following medications?
- A. Prostaglandin E2
- B. Indomethacin
- C. Methylergonovine
- D. Oxytocin
Correct Answer: B
Rationale: Indomethacin is used to delay premature labor by inhibiting uterine contractions. Prostaglandin E2, Methylergonovine, and Oxytocin are not typically used to manage preterm labor. Prostaglandin E2 can be used for cervical ripening and labor induction. Methylergonovine is used to prevent or control postpartum hemorrhage. Oxytocin is used for labor induction and augmentation of labor in term pregnancies.