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The client is 24 hours postpartum and is being discharged. The nurse explains that vaginal discharge will change from red to pink and then to white. If the client starts having red bleeding after the color changes, what should the nurse instruct the client to do?
- A. Reduce activity level and notify the healthcare provider.
- B. Go to bed and assume a knee-chest position.
- C. Massage the uterus and go to the emergency room.
- D. Do not worry as this is a normal occurrence.
Correct Answer: A
Rationale: If the client experiences red bleeding after the color changes, it may indicate possible hemorrhage or retained placental fragments, which require immediate attention. Instructing the client to reduce activity level and notify the healthcare provider is crucial for prompt evaluation and management of potential complications.
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The LPN/LVN identifies crepitus when examining the chest of a newborn who was delivered vaginally. Which further assessment should the nurse perform?
- A. Elicit a positive scarf sign on the affected side.
- B. Observe for an asymmetrical Moro (startle) reflex.
- C. Watch for swelling of fingers on the affected side.
- D. Note paralysis of the affected extremity and muscles.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
When assessing a child with HIV, which system should the nurse assess first?
- A. Assess the respiratory system.
- B. Assess the gastrointestinal system.
- C. Assess the cardiovascular system.
- D. Assess the neurological system.
Correct Answer: A
Rationale: When assessing a child with HIV, it is essential to prioritize assessing the respiratory system first. Children with HIV are more susceptible to respiratory infections and complications, such as pneumonia, due to their weakened immune system. Identifying any respiratory issues early on can help in prompt intervention and management, thus improving outcomes for the child.
The LPN/LVN is preparing a client with a term pregnancy who is in active labor for an amniotomy. What equipment should the nurse have available at the client's bedside?
- A. Litmus paper.
- B. Fetal scalp electrode.
- C. A sterile glove.
- D. Needle and Thread
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Just after delivery, a new mother tells the nurse, 'I was unsuccessful breastfeeding my first child, but I would like to try with this baby.' Which intervention is best for the LPN/LVN to implement first?
- A. Assess the husband's feelings about his wife's decision to breastfeed their baby.
- B. Ask the client to describe why she was unsuccessful with breastfeeding her last child.
- C. Encourage the client to develop a positive attitude about breastfeeding to help ensure success.
- D. Provide assistance to the mother to begin breastfeeding as soon as possible after delivery.
Correct Answer: D
Rationale: The correct intervention is to provide immediate assistance to the mother to begin breastfeeding as soon as possible after delivery. This approach helps initiate bonding and successful breastfeeding. Taking action promptly can address the mother's desire to breastfeed and promote positive outcomes for both the mother and the newborn.
A 36-week primigravida is admitted to labor and delivery with severe abdominal pain and bright red vaginal bleeding. Her abdomen is rigid and tender to touch. The fetal heart rate (FHR) is 90 beats/minute, and the maternal heart rate is 120 beats/minute. What action should the nurse implement first?
- A. Alert the neonatal team and prepare for neonatal resuscitation
- B. Notify the healthcare provider from the client's bedside
- C. Obtain written consent for an emergency cesarean section
- D. Draw a blood sample for stat hemoglobin and hematocrit
Correct Answer: B
Rationale: In this scenario, the priority action for the nurse is to notify the healthcare provider from the client's bedside. The clinical presentation of severe abdominal pain, bright red vaginal bleeding, rigid and tender abdomen, along with fetal bradycardia (FHR 90 bpm) and maternal tachycardia (120 bpm) indicates an urgent need for medical intervention. Notifying the healthcare provider promptly allows for immediate assessment and decision-making to address the critical condition and ensure timely and appropriate management for both the mother and fetus.