Nokea
Following a vaginal delivery, the postpartum nurse should observe for:
- A. Dystocia, kraurosis
- B. Chadwick's sign
- C. Fatigue, hemorrhoids
- D. Hemorrhage and infection
Correct Answer: D
Rationale: Hemorrhage and infection are critical complications to monitor post-vaginal delivery due to potential uterine or perineal issues.
You may also like to solve these questions
The client is receiving a blood transfusion. Which finding indicates a possible transfusion reaction?
- A. Temperature of 100.2°F
- B. Blood pressure of 110/70 mmHg
- C. Respiratory rate of 24 breaths per minute
- D. Itching and rash on the trunk
Correct Answer: D
Rationale: Itching and rash are signs of a possible allergic transfusion reaction, requiring immediate cessation of the transfusion. A slight temperature increase, mild hypotension, or tachypnea may occur but are less specific without other symptoms.
A client decided early in her pregnancy to breast-feed her first baby. She gave birth to a normal, full-term girl and is now progressing toward the establishment of successful lactation. To remove the baby from her breast, she should be instructed to:
- A. Gently pull the infant away
- B. Withdraw the breast from the infant's mouth
- C. Compress the areolar tissue until the infant drops the nipple from her mouth
- D. Insert a clean finger into the baby's mouth beside the nipple
Correct Answer: D
Rationale: Inserting a finger into the infant's mouth breaks suction, allowing nipple removal without trauma. Other methods risk nipple injury.
The client is diagnosed with hyperkalemia. Which food should the nurse instruct the client to avoid?
- A. Bananas
- B. Broccoli
- C. Salmon
- D. Pasta
Correct Answer: A
Rationale: Bananas are high in potassium, which should be avoided in hyperkalemia to prevent worsening arrhythmias. Broccoli, salmon, and pasta have lower potassium content.
A female client is concerned that she is in a 'high-risk' group for the development of acquired immunodeficiency syndrome (AIDS). She wants to know about the advisability of donating blood. Which of the following responses is correct?
- A. Individuals who donate blood are at risk of getting the AIDS virus. You should not donate.'
- B. It's OK for you to donate because the blood bank has a test that is 100% effective.'
- C. You should not donate since it takes time to develop antibodies to the AIDS virus. If you donate blood before you develop the antibody, you could pass it on in the blood.'
- D. It is not a good idea for you to donate. If you have AIDS, the information is made public and could destroy your personal life.'
Correct Answer: C
Rationale: The AIDS virus cannot be transmitted to the donor through the blood donation procedure. The test for the AIDS virus is not absolutely foolproof; therefore, it is not wise for a person with known risk factors to donate blood. It takes time for antibodies to the AIDS virus to develop. An infected individual could donate contaminated blood without it testing positive for the virus. For reasons of confidentiality, information about individuals infected with AIDS is not made public.
The surgical nurse is preparing a patient for surgery on the lower abdomen. In which position would the nurse most likely place the client for surgery on this area?
- A. Lithotomy
- B. Sim's
- C. Prone
- D. Trendelenburg
Correct Answer: A
Rationale: The lithotomy position is used for lower abdominal surgeries (e.g., gynecologic procedures) to provide access to the pelvic area. Sim's (B) is for rectal exams, prone (C) for back surgeries, and Trendelenburg (D) for shock or upper abdominal access.