Nokea
A postpartum client reports severe headache, visual disturbances, and epigastric pain. Which nursing action is most appropriate?
- A. Encouraging the client to rest in a dark, quiet room
- B. Providing acetaminophen for headache relief
- C. Assessing blood pressure and other vital signs
- D. Offering a massage to relieve muscle tension
Correct Answer: C
Rationale: The most appropriate nursing action in this situation is to assess the client's blood pressure and other vital signs. The client's symptoms of severe headache, visual disturbances, and epigastric pain could be indicative of preeclampsia or eclampsia, which are serious conditions that require immediate medical attention. Checking the blood pressure and other vital signs will help determine if the client's symptoms are related to abnormal blood pressure levels, which is critical in identifying and managing hypertensive disorders in postpartum clients. Once the assessment is completed, appropriate medical interventions can be initiated promptly if necessary.
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Which medication will be prescribed to control and maintain the blood pressue of patients at normal level?
- A. Lidocaine
- B. Amlodipine
- C. Epinephrine
- D. Furosemide
Correct Answer: B
Rationale: Amlodipine is a medication commonly prescribed to control and maintain blood pressure at normal levels. It belongs to a class of drugs known as calcium channel blockers, which work by relaxing and widening blood vessels, making it easier for the heart to pump blood around the body. This ultimately helps to lower blood pressure and reduce the workload on the heart, decreasing the risk of cardiovascular events like heart attacks and strokes. Lidocaine, Epinephrine, and Furosemide are not typically used for controlling and maintaining blood pressure within normal limits.
A patient presents with fever, chills, and costovertebral angle tenderness. Urinalysis reveals pyuria and bacteriuria. Which of the following conditions is most likely?
- A. Acute pyelonephritis
- B. Chronic kidney disease
- C. Urinary tract infection (UTI)
- D. Renal calculi
Correct Answer: A
Rationale: Acute pyelonephritis is the most likely condition based on the patient presentation and urinalysis findings described. Acute pyelonephritis is an infection of the renal parenchyma and pelvis, typically caused by ascending bacteria from the lower urinary tract. The classic symptoms include fever, chills, flank pain, and costovertebral angle tenderness (tenderness over the kidneys). The presence of pyuria (pus in the urine) and bacteriuria (bacteria in the urine) on urinalysis further supports the diagnosis of acute pyelonephritis. It is crucial to diagnose and treat acute pyelonephritis promptly to prevent complications and recurrent infections.
On the first postpartum day, a primiparous patient complains of perineal pain that was unrelieved by Ibuprofen 400 mg given two hours ago. Nurse Kayla should assess for which of the following?
- A. Vaginal laceration
- B. History of Drug Abuse
- C. Perineal hematoma
- D. Puerperal infection
Correct Answer: C
Rationale: In a primiparous patient who complains of unrelieved perineal pain on the first postpartum day, Nurse Kayla should assess for a perineal hematoma. A perineal hematoma is a collection of blood in the perineal tissues and can cause significant pain and discomfort. It can be a result of trauma during delivery or due to a blood vessel rupture. This condition requires prompt assessment and intervention to prevent complications such as infection or excessive bleeding. Vaginal laceration would typically be identified during the delivery process and would have been repaired by the healthcare provider. History of drug abuse, while important to know for overall patient care, is not as relevant in this immediate postpartum pain assessment. Puerperal infection usually presents with other signs such as fever, foul-smelling discharge, and uterine tenderness, which are not mentioned in this scenario.
A postpartum client who delivered vaginally expresses concern about feeling "heavy" in the perineal area. What education should the nurse provide to address this sensation?
- A. Encourage the client to perform Kegel exercises regularly.
- B. Recommend the use of perineal pads for additional support.
- C. Educate the client about the process of uterine involution.
- D. Suggest the use of a perineal support garment.
Correct Answer: A
Rationale: The sensation of feeling "heavy" in the perineal area postpartum is a common concern due to the stretching and potential trauma to the perineal muscles during childbirth. Kegel exercises are specifically designed to strengthen the pelvic floor muscles, which can help alleviate this sensation of heaviness. By encouraging the client to perform Kegel exercises regularly, the nurse is promoting the restoration and strengthening of the perineal muscles, ultimately helping the client feel more comfortable and supported in that area. This education empowers the client to take an active role in their own recovery and promotes optimal healing postpartum.
Which of the following clinical manifestations would the nurse expect to find when performing admission assessment?
- A. Rapid progressive muscular atrophy.
- B. Ascending paralysis with ataxia .
- C. Hyperactive deep tendon reflexes
- D. Paresthesia and muscle weakness of upper body.
Correct Answer: D
Rationale: When performing an admission assessment, the nurse should expect to find clinical manifestations that are indicative of a variety of conditions. Paresthesia (abnormal sensation like tingling, prickling, or numbness) and muscle weakness of the upper body are commonly associated with neurological conditions such as peripheral neuropathy or cervical radiculopathy. These symptoms suggest dysfunction in the nerves that supply the upper body muscles, leading to sensory changes and weakness. This finding would prompt further assessment and evaluation by healthcare providers to determine the underlying cause and appropriate interventions. Rapid progressive muscular atrophy, ascending paralysis with ataxia, and hyperactive deep tendon reflexes are not typically expected findings during an admission assessment and may signal more specific neurological conditions such as amyotrophic lateral sclerosis, Guillain-Barré syndrome, or spinal cord injury, respectively.