Nokea
The client delivered a healthy newborn 4 hours ago after being induced with oxytocin. While being assisted to the bathroom to void for the first time after delivery, the client tells the nurse that she doesn’t feel a need to urinate. Which explanation should the nurse provide when the client expresses surprise after voiding 900 mL of urine?
- A. “A decreased sensation of bladder filling is normal after childbirth.”
- B. “The oxytocin you received in labor makes it difficult to feel voiding.”
- C. “You probably didn’t empty completely. I will need to scan your bladder.”
- D. “Your bladder capacity is large; you likely won’t void again for 6—8 hours.”
Correct Answer: A
Rationale: The nurse should explain about the decreased sensation of bladder filling after childbirth. It is not uncommon for the postpartum client to have increased bladder capacity, decreased sensitivity to fluid pressure, and a decreased sensation of bladder filling. Oxytocin (Pitocin) is not expected to cause a change in bladder sensation, but it does have an antidiuretic effect. There is no indication that the client didn’t completely empty; a volume of 900 mL is a large amount. The postpartum client is at risk for bladder overdistention and should be encouraged to void every 2 to 4 hours.
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The nurse is providing nutrition counseling to a primigravida who is 10 weeks pregnant. Which meal choice stated by the client indicates she needs additional information?
- A. Black beans, wild rice, collard greens
- B. Dry cereal, milk, dried cranberries
- C. Tuna, broccoli, baked potato
- D. Beef strips, lentils, red peppers
Correct Answer: C
Rationale: Tuna contains mercury and should be limited in pregnancy due to risk of mercury poisoning. The nurse should provide this additional information. Black beans provide a good source of calcium, iron, and protein. Black beans, wild rice, and collard greens provide fiber. Collard greens provide a good source of calcium and folic acid. Dry cereal provides a good source of vitamin D, milk provides a good source of calcium, and dried cranberries provide a good source of calcium and iron. Beef provides a good source of protein and iron, lentils provide a good source of iron, and red peppers provide a good source of vitamin C.
The nurse advises the client to perform which exercise to strengthen pelvic floor muscles?
- A. Kegel exercises
- B. High-impact aerobics
- C. Sit-ups
- D. Weightlifting
Correct Answer: A
Rationale: Kegel exercises strengthen pelvic floor muscles, aiding postpartum recovery and preventing incontinence.
The nurse is reviewing the laboratory test results of the pregnant client. Which laboratory test findings would require further follow-up from the nurse?
- A. Hemoglobin
- B. 50-g, 1-hour glucose test
- C. Glucosuria
- D. Proteinuria
Correct Answer: A
Rationale: The normal Hgb level should be 12—16 g/dL in the pregnant client. The nurse should encourage iron-rich foods. The 50-g 1-hour glucose test should be less than 140. Values over 140 warrant a 3-hour glucose screen to determine if the client has gestational diabetes. The presence of glucose in the urine (glucosuria) is negative, which is a normal finding. Proteinuria in trace amounts is common in pregnant women, although higher protein concentrations should be evaluated.
Which assessment finding best indicates the presence of this condition?
- A. Painful blisters on the labia
- B. Heavy, grayish white discharge
- C. Milky white discharge that smells like fish
- D. Thick, white, curdlike vaginal discharge
Correct Answer: B
Rationale: Chlamydia often presents with heavy, grayish-white discharge, unlike the other options, which suggest different infections.
At one minute after birth, a neonate is pink, except for blue extremities. The neonate is crying, gagging, and grimacing when the bulb syringe is used and has some flexion of extremities and an HR of 97. Based on the Apgar score, what should the nurse do next?
- A. Notify the health care provider
- B. Recheck the Apgar at 5 minutes after birth
- C. Initiate resuscitation measures immediately
- D. Swaddle and hand to mother for breastfeeding
Correct Answer: B
Rationale: Rechecking the Apgar score at 5 minutes after birth will determine if the newborn is continuing to make a good transition to the extrauterine environment. Notifying the HCP is not necessary at this time. The one-minute Apgar score is 6, very close to the 7 to 10 normal limits. This newborn has a good cry, indicating good transition to the extrauterine environment thus far. Initiating resuscitation measures immediately is not necessary. This would be done if the newborn were not crying and demonstrated a blue or pale body. Swaddling and giving the newborn to the mother for breastfeeding are important but should occur after the 5-minute Apgar, if the score is WNL. Keeping this newborn in the radiant warmer, rather than giving him or her to the mother, will help prevent hypothermia and promote better transition to extrauterine life.