The nurse is caring for a client in the postpartum period. What finding indicates a need for immediate intervention?
- A. Fundus firm and midline.
- B. Lochia rubra with large clots.
- C. Perineal pain after delivery.
- D. Slight swelling of the feet.
Correct Answer: B
Rationale: Large clots in lochia rubra may indicate retained placental fragments or postpartum hemorrhage.
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The laboring person asks the nurse to review the birth plan. What item is on a typical birth plan?
- A. where the patient will be staying after birth
- B. who will be watching their other children
- C. what position they want to birth in
- D. how they will time contractions
Correct Answer: C
Rationale: Birth plans often include preferences for birthing positions to promote comfort and effectiveness.
The nurse is preparing a client for a nonstress test. What instruction is most appropriate?
- A. You need to fast for 12 hours before the test.
- B. You will be given medication to stimulate fetal movements.
- C. You will need to press a button each time you feel the baby move.
- D. You must lie flat on your back during the test.
Correct Answer: C
Rationale: The client presses a button during fetal movements, which are correlated with fetal heart rate changes.
Which lifestyle factor is associated with an increased risk of developing breast cancer?
- A. regular physical activity
- B. moderate alcohol consumption
- C. maintaining a healthy weight after menopause
- D. excessive alcohol consumption
Correct Answer: D
Rationale:
The nurse is assessing a client diagnosed with placenta previa. Which findings should the nurse expect to note?
- A. Uterine rigidity.
- B. Severe abdominal pain.
- C. Bright red vaginal bleeding.
- D. Soft, relaxed, nontender uterus.
Correct Answer: C
Rationale: Placenta previa presents as painless bright red bleeding and a soft, non-tender uterus.
What history would lead you to suspect an ectopic pregnancy in a client at 8 weeks' gestation presenting with abdominal pain and bleeding?
- A. Treated one year ago for PID
- B. Irregular cycle for 1 year
- C. Oral contraception for 3 years
- D. Urinary frequency for 1 week
Correct Answer: A
Rationale: A history of previous pelvic inflammatory disease (PID) treatment would lead to suspicion of an ectopic pregnancy in a client presenting with abdominal pain and bleeding at 8 weeks' gestation. PID can cause scarring and damage to the fallopian tubes, increasing the risk of an ectopic pregnancy where the fertilized egg implants outside of the uterus, usually in the fallopian tubes. Symptoms of an ectopic pregnancy can include abdominal pain, vaginal bleeding, and signs of shock, making it important to consider this possibility in a client with a history of PID.