Nokea
Following the vaginal delivery of a large-for-gestation-age (LGA) infant a woman is admitted to the intensive care unit due to postpartum hemorrhaging. The client's medical record lists the client's religion as Jehovah's Witness. What action should the nurse take?
- A. Prepare to infuse multiple units of fresh frozen plasma
- B. Inform the client of the critical need for a blood transfusion
- C. Clarify the clients wishes about receiving blood products
- D. Obtain consent from the family to infuse packed red blood cells
Correct Answer: C
Rationale: Clarifying the client's wishes regarding blood products (C) respects her religious beliefs.
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The nurse is teaching a woman how to use her basal body temperature (BBT) pattern as a tool to assist her in conceiving a child. Which temperature pattern indicates the occurrence of ovulation, and therefore, the best time for intercourse to ensure conception?
- A. Between the time the temperature falls and rises
- B. Between 36 and 48 hours after the temperature rises
- C. When the temperature falls and remains low for 36 hours
- D. Within 72 hours before the temperature falls
Correct Answer: A
Rationale: In most women, the BBT drops slightly 24 to 36 hours before ovulation and rises 24 to 72 hours after ovulation, when the corpus luteum of the ruptured ovary produces progesterone. Therefore, intercourse between the time of the temperature fall and rise (A) is the best time for conception.
Client teaching is an important part of the maternity nurse's role. Which factor has the greatest influence on successful teaching on the gravid client?
- A. The client's readiness to learn
- B. The client's educational background
- C. The order in which the information is presented
- D. The extent to which the pregnancy was planned
Correct Answer: A
Rationale: When teaching any client, readiness to learn (A) is the most important criterion. For example, the client with severe morning sickness in the first trimester may not be 'ready to learn' about ways to relieve morning sickness.
The nurse is caring for a postpartum client who is complaining of severe pain and a feeling of pressure in her perineum. Her fundus is firm, and she has a moderate lochia flow. On inspection the nurse finds that a perineal hematoma is beginning to form. Which assessment findings show the nurse obtain first?
- A. Abdominal contour and bowel sounds
- B. Hemoglobin and hematocrit
- C. Heart rate and blood pressure
- D. Urinary output and IV fluid intake
Correct Answer: C
Rationale: Hematomas can cause significant blood loss, so assessing heart rate and blood pressure (C) is critical.
Which patient has correctly increased her caloric intake from her recommended pregnancy intake to the amount necessary to sustain breastfeeding in the first 6 postpartum months?
- A. From 1800 to 2200 calories per day
- B. From 2000 to 2500 calories per day
- C. From 2200 to 2530 calories per day
- D. From 2500 to 2730 calories per day
Correct Answer: C
Rationale: Rationale: The correct answer is C because for breastfeeding, an additional 500 calories/day are needed compared to pregnancy. The recommended caloric intake during pregnancy is around 2200 calories/day. Therefore, increasing from 2200 to 2530 calories/day aligns with the additional 500 calories necessary for sustaining breastfeeding.
Summary:
A: Going from 1800 to 2200 calories/day does not provide the extra 500 calories needed for breastfeeding.
B: Increasing from 2000 to 2500 calories/day does not account for the original pregnancy intake or the additional calories required for breastfeeding.
D: Jumping from 2500 to 2730 calories/day exceeds the additional 500 calories needed for breastfeeding, potentially leading to excessive weight gain.
A client at 30-weeks gestation, complaining of pressure over the pubic area, is admitted for observation. She is contracting irregularly and demonstrates underlying uterine irritability. Vaginal examination reveals that her cervix is closed, thick, and high. Based on these data, which intervention should the nurse implement first?
- A. Provide oral hydration
- B. Have a complete blood count (CBC) drawn
- C. Obtain a specimen for urine analysis
- D. Place the client on strict bedrest
Correct Answer: C
Rationale: Obtaining a urine analysis (C) should be done first because preterm clients with uterine irritability and contractions are often suffering from a urinary tract infection, and this should be ruled out first.