Nokea
The client is diagnosed with moderate postpartum depression (PPD) after vaginal delivery of a 10 lb baby. One week following the delivery, the nurse is completing a home visit. Which finding should be the nurse’s priority?
- A. Lochia has a foul-smelling odor.
- B. Small but tender hemorrhoids.
- C. Yells at her baby to stop crying.
- D. Client cries throughout the visit.
Correct Answer: C
Rationale: Lochia that is foul smelling could indicate that the client has a postpartum infection. The client needs to be seen by an HCP, but the safety of the infant is priority. The presence of tender hemorrhoids may be uncomfortable and should be addressed, but this is not priority. It is inappropriate for the client to yell at her baby to stop crying. Verbal abuse can escalate to physical abuse. The safety of the infant should be the nurse’s priority. Persistent crying is a sign of PPD and would be expected. However, persistent crying should be further explored because treatment may be ineffective.
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The nurse is assessing the client who is 34 weeks’ gestation. Place an X where the nurse should place the Doppler first to assess the FHR when the fetus is thought to be left occiput anterior (LOA).
Correct Answer:
Rationale: FHT are best heard in the lower left quadrant of the client’s abdomen when the fetus is LOA.
The client presents with vaginal bleeding at 7 weeks. Which action should be taken by the nurse first?
- A. Take the client’s vital signs
- B. Prepare examination equipment
- C. Give 2 liters oxygen per nasal cannula
- D. Assess the client’s response to the situation
Correct Answer: A
Rationale: Assessing the client’s VS should be completed first. Bleeding can cause hypotension. Although preparing examination equipment is important, the nurse should first focus on the client. Having oxygen available is important, but there is no indication that the client needs oxygen at this time. Assessing the client’s response is important, but assessment of physiological problems should occur first.
The nurse is doing a one-minute Apgar score on a newborn and tells the parents that it is 7 points. When the parents ask what this means, how should the nurse best respond?
- A. “This score is good, but the baby needs to have a score of 10 in five minutes.”
- B. “The Apgar score can predict intelligence and neurological development.”
- C. “Your baby is fine and should have no difficulty adapting outside the womb.”
- D. “Your baby has good vital signs and is classified as full-term gestational age.”
Correct Answer: C
Rationale: This response is best because a score of 7 to 10 is within a normal range and 并表示新生儿没有任何不适的迹象。A score of 7 to 10 is considered acceptable for a one-minute Apgar. However, when the scoring is repeated at 5 minutes of age, a score of 7 to 10, not just 10, is within normal range. The Apgar score is used to systematically assess an infant at one and five minutes after birth to determine if immediate care is necessary. It is not used to predict intelligence or neurological development. Although the Apgar score does mean that the newborn’s VS are WNL, the Apgar score is not designed to classify gestational age.
On the basis of this finding, the nurse can assume that the client is at least how many months' pregnant?
- A. 5 months
- B. 6 months
- C. 7 months
- D. 8 months
Correct Answer: A
Rationale: Ballottement, the rebound of the fetus when the cervix is tapped, is typically detectable around 4-5 months, indicating at least 5 months' gestation.
Which finding indicates a need for further evaluation during a prenatal visit?
- A. Blood pressure of 120/80 mmHg
- B. Trace protein in urine
- C. Weight gain of 1 pound per week
- D. Fetal heart rate of 140 bpm
Correct Answer: B
Rationale: Trace protein in urine may indicate early preeclampsia or kidney issues, warranting further evaluation.