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The nurse is collecting data from the client 24 hr later.
How should the nurse interpret the findings?
- A. Moderate lochia rubra: Sign of potential improvement.
- B. Client reports decreased level of pain: Sign of potential improvement.
- C. Temperature 38.4°C (101°F): Sign of potential worsening condition.
- D. WBC count 15,000/mm³ : Sign of potential worsening condition.
Correct Answer: C
Rationale: A temperature of 38.4°C (101°F) suggests a potential infection or inflammatory process, indicating a worsening condition.
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A nurse is reinforcing teaching about preventing mastitis with a client who is breastfeeding.
Which of the following instructions should the nurse include?
- A. You should use a breast pump if you plan to return to work.
- B. Cover your breasts immediately after feedings.
- C. Wash your nipples with soap and water daily.
- D. Wear an underwire bra between feedings.
Correct Answer: A
Rationale: Using a breast pump prevents engorgement and maintains milk flow, reducing mastitis risk when returning to work.
History and Physical: The client reports a history of one previous cesarean section due to breech presentation. She smokes half a pack of cigarettes daily and has a BMI greater than 30. The client denies leakage of amniotic fluid and describes positive fetal movement. Vital Signs: Temperature: 98.6°F (37°C), Pulse: 88 beats/min, Respiratory Rate: 16 breaths/min, Blood Pressure: 128/78 mmHg, Oxygen Saturation: 98% on room air. Nurses' Notes (0830 and 0845): 0830: The client is grimacing and reports discomfort. Fetal heart rate is 148 beats per minute. Fundal height measures 28 cm. 0845: Uterine contractions every 2 to 3 minutes, moderate in intensity, lasting 60 seconds.
The nurse should recommend to first address the client's ___, followed by the client's ___.
- A. Uterine contraction frequency
- B. History of cesarean delivery
Correct Answer: A,B
Rationale: Frequent contractions indicate preterm labor risk at 30 weeks; prior cesarean increases uterine rupture risk, both needing prompt attention.
A nurse is caring for a 37-year-old female client in the labor and delivery unit in early labor with contractions and reports feeling fetal movement.
The nurse should anticipate a provider's prescription for ___ due to the client’s ___.
- A. Continuous fetal monitoring , term gestation with regular contractions
- B. regular exercise,fetal positioning
Correct Answer: A
Rationale: Continuous fetal monitoring ensures observation of fetal heart rate and labor progress in a term client with regular contractions.
A nurse is reinforcing teaching about preterm labor with a client who is at 28 weeks of gestation.
Which of the following statements by the client indicates an understanding of the teaching?
- A. I should expect to feel pain in my upper right abdomen if I am having preterm labor.
- B. I have contractions more often than every 10 minutes. I might be in preterm labor.
- C. I might be experiencing preterm labor if walking stops my contractions.
- D. I can take a daily iron supplement to prevent preterm labor.
Correct Answer: B
Rationale: Frequent contractions (more than every 10 minutes) indicate preterm labor, showing understanding of a key symptom.
The nurse should first address the client's blood pressure followed by the client's platelet count.
Which of the following options correctly prioritizes these actions?
- A. Blood pressure should be checked before platelet count.
- B. Platelet count is more important than blood pressure.
- C. Address both simultaneously.
- D. Ignore blood pressure.
Correct Answer: A
Rationale: Blood pressure should be checked first as it indicates immediate hemodynamic status, critical in acute settings, followed by platelet count for bleeding risk.