Nokea
One hour postdelivery the nurse notes the new mother has saturated three perineal pads. What is the most appropriate nursing action?
- A. Check the fundus for position and firmness.
- B. Report to the doctor immediately.
- C. Change the pads and chart the time.
- D. Time how long it takes to soak one pad.
Correct Answer: A
Rationale: Increased lochia may indicate hemorrhage. The fundus should be assessed for firmness. One pad an hour is an acceptable rate for immediate postdelivery.
You may also like to solve these questions
What is the nurse's most informative response?
- A. When you feel increased fetal movement
- B. When contractions are 10 minutes apart
- C. When membranes have ruptured
- D. When abdominal or groin discomfort occurs
Correct Answer: C
Rationale: Ruptured membranes are an indication that the woman should go to the hospital or birthing center.
While caring for an Arab woman in labor, the nurse should provide cultural sensitivity through which interventions?
- A. Provide for extreme modesty.
- B. Assign a male caregiver.
- C. Arrange for the husband/partner to participate in labor.
- D. Provide adequate pain control.
- E. Respect protective amulets.
Correct Answer: A,D,E
Rationale: Arab women are extremely modest, usually have a low pain tolerance, and wear protective amulets. Female caregivers are preferred, and the husband is present but not a participant.
What are the advantages of a freestanding birth center?
- A. Homelike setting
- B. Designed for high-risk pregnancies
- C. Lower costs
- D. Attended by certified obstetricians
- E. Immediate emergency access
Correct Answer: A,C
Rationale: Advantages of a freestanding birth center include a homelike setting and lower costs, as they do not require expensive departments like emergency or critical care.
While caring for a laboring woman, the nurse notices a pattern of variable decelerations in fetal heart rate with uterine contractions. What is the nurse's initial action?
- A. Stop the oxytocin infusion.
- B. Increase the intravenous flow rate.
- C. Reposition the woman on her side.
- D. Start oxygen via nasal cannula.
Correct Answer: C
Rationale: Repositioning the woman is the first response to a pattern of variable decelerations. If the decelerations continue, then oxygen should be administered and/or the flow rate of oxygen should be increased.
What will the nurse remind the patient about contractions during this stage of labor?
- A. They get the infant positioned for delivery.
- B. They push the infant into the vagina.
- C. They dilate and efface the cervix.
- D. They get the mother prepared for true labor.
Correct Answer: C
Rationale: The first stage of labor describes the time from the onset of labor until full dilation of the cervix.