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One day after vaginal delivery of a full-term baby, a postpartum client's white blood cell (WBC) count is 15,000/mm³ (15 x 10â¹/L). Which action should the nurse take first?
- A. Check the differential, since the WBC is normal for this client.
- B. Assess the client's perineal area for signs of a perineal hematoma.
- C. Assess the client's temperature, heart rate, and respirations every 4 hours.
- D. Notify the healthcare provider (HCP), since this finding is indicative of infection.
Correct Answer: A
Rationale: A WBC count of 15,000/mm³ is normal postpartum due to physiological stress; checking the differential confirms this, avoiding unnecessary interventions.
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A nurse is conducting a preconception class for a group of parents who are anticipating having children. Which client(s) should the nurse refer for genetic counseling? (Select all that apply)
- A. A couple who express concern about birth defects after using an internet DNA testing site.
- B. A woman and her significant other who are excited about the prospect of having children.
- C. A woman planning to start a second family after the loss of an embryo following an in-vitro fertilization procedure.
- D. A man who states that his father was recently diagnosed with Huntington's disease.
- E. A couple who plan to use in-vitro fertilization with donated sperm.
Correct Answer: A,C,D,E
Rationale: Concerns about birth defects, embryo loss, Huntington's disease, and donor sperm use indicate potential genetic risks requiring counseling, unlike general excitement about having children.
A client in the third trimester of pregnancy is troubled by frequent nasal stuffiness and occasional nosebleeds. Her chest circumference has increased by 5 cm during the pregnancy, and she uses thoracic breathing. Her diaphragm is elevated and she has an increased costal angle. Which intervention should the nurse implement?
- A. Ask a nurse with more experience to validate the costal angle finding.
- B. Examine the client for signs of tissue anoxia, such as pallor.
- C. Ask the healthcare provider to evaluate the client's respiratory status.
- D. Record the respiratory finding in the client's record as normal.
Correct Answer: D
Rationale: These respiratory changes are normal pregnancy adaptations due to uterine expansion, requiring only documentation as normal findings.
History and Physical:
Nurses' Notes:
Vital Signs
The neonate was born vaginally at 0130 to a 32-year-old gravida 3, para 3, abortion 0 (G3P3A0) mother. The neonate was born at 39 weeks gestation. The mother had an uncomplicated pregnancy and delivery.
The nurse evaluates the data presented. Complete the diagram by specifying which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
- A. Potential Conditions: Altered respiratory function, Hypoglycemia, Thermoregulation, Sepsis, Hyperbilirubinemia
- B. Actions: Provide manual breaths with a bag-valve mask (BVM), Give dextrose solution orally, Administer intravenous (IV) antibiotics, Place the neonate under a radiant warmer, Perform a heel stick for blood glucose testing
- C. Parameters: Respiratory rate, Temperature, Blood glucose levels, Oxygen saturation, Bilirubin levels
Correct Answer: B,E,C
Rationale: Hypoglycemia is likely due to jitteriness and low temperature; oral dextrose and heel stick glucose testing address it, while monitoring glucose levels and temperature tracks progress.
The current vital signs for a primipara who delivered vaginally during the previous shift are: temperature 100.4° F (38° C), heart rate 58 beats/minute, respiratory rate 16 breaths/minute, and blood pressure 130/74 mm Hg. Which action should the nurse implement?
- A. Administer a PRN dose of acetaminophen.
- B. Assess perineum for excessive lochia.
- C. Document the vital signs in the record.
- D. Report heart rate to healthcare provider.
Correct Answer: C
Rationale: These vital signs are normal postpartum; documenting them ensures accurate tracking without unnecessary interventions.
A woman who is trying to get pregnant tells the nurse that she was very disappointed several months ago when she was informed that her positive pregnancy test was a false positive. Which method of determining pregnancy provides the greatest degree of accuracy?
- A. Visualization of implantation by vaginal ultrasound.
- B. Maternal blood serum tests positive for alpha-fetoprotein.
- C. Presence of amenorrhea for 2 months.
- D. Reports feeling tired all of the time.
Correct Answer: A
Rationale: Vaginal ultrasound directly visualizes the implanted embryo, providing the highest accuracy compared to biochemical tests or subjective symptoms, which can be misleading.