Nokea
The client, who is 12 days postpartum, telephones the clinic and tells the nurse that she is concerned that she may have an infection because her vaginal discharge has been creamy white for two days now. Which response by the nurse is correct?
- A. “You need to come to the clinic as soon as possible.”
- B. “You’ll need an antibiotic; which pharmacy do you use?”
- C. “Take your temperature and let me know if it is elevated.”
- D. “A creamy white discharge 10 days postpartum is normal.”
Correct Answer: D
Rationale: There is no need to be seen in the clinic; vaginal discharge that turns creamy white 10 days postpartum is normal. The client does not have an infection, and no antibiotic is necessary. There is no reason to take her temperature when the discharge is normal. Creamy white discharge 10 to 21 days postpartum is normal. Her lochia changed color on her 10th postpartum day.
You may also like to solve these questions
The pregnant client tells the nurse that she smokes two packs per day (PPD) of cigarettes, has smoked in other pregnancies, and has never had any problems. What is the nurse’s best response?
- A. “I’m glad that your other pregnancies went well. Smoking can cause both maternal and fetal problems, and it is best if you could quit smoking.”
- B. “You need to stop smoking for the baby’s sake. You could have a spontaneous abortion with this pregnancy if you continue to smoke.”
- C. “Smoking can lead to having a large baby, which can make delivery difficult. You may even need a cesarean section.”
- D. “Smoking less would eliminate the risk for your baby, and you would feel healthier during your pregnancy.”
Correct Answer: A
Rationale: The nurse is acknowledging that the client did not experience problems with her other pregnancies but is also informing the client that smoking can cause maternal and fetal problems during pregnancy. Telling the client to stop smoking for the baby’s sake is confrontational, making the client less likely to listen to the nurse’s teaching. Although spontaneous abortion is associated with tobacco use during pregnancy, the nurse is using a scare tactic rather than therapeutic communication. Smoking can lead to a fetus that is small for gestational age, not a large baby. Decreasing her smoking intake should be suggested; however, it does not eliminate the risk to the baby completely.
The client at 31 weeks’ gestation is diagnosed with mild preeclampsia and placed on home management. What information should the nurse include when providing home management instructions? Select all that apply.
- A. “Plan for hospitalization when nearing 36 weeks’ gestation.”
- B. “Weigh daily and inform the HCP of a sudden increase in weight.”
- C. “Home care will be consulted to take your blood pressure (BP) daily.”
- D. “Perform stretching and range-of-motion exercises twice daily.”
- E. “Rest as much as possible, especially in the lateral recumbent position.”
Correct Answer: B,D,E
Rationale: A sudden weight gain could indicate that the mild preeclampsia is uncontrolled and the client is retaining fluid. The HCP should be consulted. Stretching and ROM exercises can help prevent thrombophlebitis and venous stasis. The lateral recumbent position improves uteroplacental blood flow, reduces maternal BP, and promotes diuresis. A diagnosis of mild preeclampsia does not require hospitalization during the antepartum period unless home management fails to reduce the client’s BP, or other complications occur. BP monitoring every 4 to 6 hours is recommended for the client with mild preeclampsia, but the BP can be taken by the client and does not require a consult with home care.
An LPN asks an RN to assist in locating the fundus of the client who is 8 hours post—vaginal delivery. Place an X at the location on the client’s abdomen where the RN should direct the LPN to begin to palpate the fundus.
Correct Answer: Level of the umbilicus
Rationale: Six to 12 hours after birth, the fundus of the uterus rises to the level of the umbilicus due to blood and clots that remain within the uterus and changes in ligament support. Thus, the RN should direct the LPN to locate the client’s fundus at the level of the umbilicus.
Which response by the nurse about Chadwick's sign is most accurate?
- A. It's a bluish discoloration of the cervix, vagina, and vulva that occurs as a result of the presence of an increased number of blood vessels.
- B. It's a softening of the cervix that occurs because of an increased amount of blood flowing to the reproductive organs.
- C. It's a dark brown line extending from the umbilicus to the symphysis pubis that occurs as a result of hormonal changes.
- D. None of the above
Correct Answer: A
Rationale: Chadwick's sign is the bluish discoloration of the cervix, vagina, and vulva due to increased vascularity, a probable sign of pregnancy.
The nurse observes on the monitor tracing of the client in the transition phase of labor that the baseline FHR is 160 and that there is moderate variability with V-shaped decelerations unrelated to contractions. What should the nurse do first?
- A. Prepare for delivery.
- B. Notify the obstetrician.
- C. Apply oxygen nasally.
- D. Reposition the client.
Correct Answer: D
Rationale: Repositioning the client to her side or to knee-chest should be done first to take the pressure off the umbilical cord. Variable decelerations usually result from cord compression and stretching during fetal descent. The fetus has a normal baseline HR and good variability. There is no indication that immediate delivery is necessary. Other measures could correct the V-shaped (variable) decelerations. Other nursing measures are used to correct the V-shaped (variable) decelerations prior to contacting the obstetrician (or midwife). Repositioning the client should be implemented prior to giving her oxygen.