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On the first postpartum day, the primiparous client reports perineal pain of 5 on a scale of 1 to 10 that was unrelieved by ibuprofen 800 mg given 2 hours ago. The nurse should further assess the client for:
- A. Puerperal infection.
- B. Vaginal lacerations.
- C. History of drug abuse.
- D. Perineal hematoma.
Correct Answer: D
Rationale: Persistent perineal pain unrelieved by ibuprofen suggests a perineal hematoma, which requires further assessment.
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After circumcision with a Plastibell, the nurse should instruct the neonate's mother to cleanse the circumcision site with which of the following?
- A. Warm water.
- B. Povidone-iodine (Betadine) solution.
- C. Diluted hydrogen peroxide.
Correct Answer: A
Rationale: Warm water is recommended for cleansing the circumcision site to keep it clean and promote healing without causing irritation.
A 21-year-old primigravid client at 40 weeks' gestation is admitted to the hospital in active labor. The client's cervix is 8 cm and completely effaced at 0 station. During the transition phase of labor, which of the following is a priority nursing diagnosis?
- A. Impaired urinary elimination related to nothing-by-mouth status.
- B. Risk for injury related to hyperventilation and dizziness.
- C. Ineffective coping related to lack of confidence.
- D. Pain related to increasing frequency and intensity of uterine contractions.
Correct Answer: D
Rationale: During the transition phase (8–10 cm), intense and frequent contractions cause significant pain, making pain management the priority nursing diagnosis. Urinary elimination issues are less urgent, hyperventilation is a secondary concern, and coping issues are not as immediate as pain.
Four days after a vaginal delivery, the client visits the clinic complaining of excessive lochia rubra with clots. The physician orders methylergonovine maleate (Methergine), 0.2 mg intramuscularly. Before administering this drug, the nurse should assess:
- A. Blood pressure.
- B. Pulse rate.
- C. Breath sounds.
- D. Bowel sounds.
Correct Answer: A
Rationale: Methylergonovine can cause hypertension, so blood pressure assessment is essential before administration.
Two hours after vaginally delivering a viable male neonate under epidural anesthesia, the client with a midline episiotomy ambulates to the bathroom to void. After voiding, the nurse assesses the client's bladder, finding it distended. The nurse interprets this finding based on the understanding that the client's bladder distention is most likely caused by which of the following?
- A. Prolonged first stage of labor.
- B. Urinary tract infection.
- C. Pressure of the uterus on the bladder.
- D. Edema in the lower urinary tract area.
Correct Answer: D
Rationale: Edema in the lower urinary tract, often from delivery trauma or epidural anesthesia, can cause urinary retention and bladder distention.
A primiparous client bottle-feeding her neonate asks about sterilizing bottles. The nurse should instruct the client to:
- A. Boil bottles for 10 minutes after each use.
- B. Use a dishwasher with a sanitize cycle.
- C. Soak bottles in bleach solution daily.
- D. Wash bottles with hot soapy water only.
Correct Answer: B
Rationale: A dishwasher with a sanitize cycle effectively sterilizes bottles, ensuring safety for the neonate.