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Which circumstance is most likely to cause uterine partum assessment with a woman who is 4 days atony and lead to excessive blood loss?
- A. Orthostatic hypotension
- B. Involution of the uterus
- C. Urine retention
- D. Afterpains
Correct Answer: A
Rationale: Orthostatic hypotension, which is a sudden drop in blood pressure upon standing, can result in decreased perfusion to the uterus, leading to poor contraction of the uterine muscles. This can result in uterine atony, where the uterus fails to contract properly after delivery. Uterine atony is a common cause of excessive postpartum bleeding (postpartum hemorrhage). Without proper contraction of the uterus, the blood vessels that supplied the placenta during pregnancy remain open and bleeding can continue unchecked.
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A nurse is caring for a client 2 hr after a spontaneous vaginal birth and the client has saturated two perineal pads with blood in a 30-min period. Which of the following is the priority nursing intervention at this time?
- A. Palpate the client's uterine fundus.
- B. Assist the client on a bedpan to urinate.
- C. Prepare to administer oxytocic medication.
- D. Increase the client's fluid intake.
Correct Answer: A
Rationale: The priority nursing intervention in this situation is to palpate the client's uterine fundus. Saturating two perineal pads with blood in a 30-minute period after childbirth is indicative of excessive postpartum bleeding, also known as postpartum hemorrhage (PPH). Palpating the uterine fundus helps the nurse assess for uterine atony, a common cause of PPH. If the fundus is boggy or not firm, it indicates that the uterus is not contracting effectively to control bleeding, which can lead to further complications if not addressed promptly. Once uterine atony is identified, other interventions such as administering oxytocic medications can be initiated to help the uterus contract and control bleeding.
During a nursing assessment the woman with rupture
- A. What is the nurse's priority action?
- B. Use gravity and manipulation to relieve compression of the cord (butt up in the air and face down until ready to delivery)
- C. Help the fetal head descend faster
- D. Facilitate dilation of the cervix with prostaglandin gel
Correct Answer: A
Rationale: In the scenario presented, the nurse's priority action should be to call for emergent medical assistance. A woman with a rupture during a nursing assessment could be experiencing a serious complication known as umbilical cord prolapse. This occurs when the umbilical cord slips through the cervix ahead of the baby, which can lead to compression of the cord and a serious decrease in oxygen supply to the baby. It is a medical emergency that requires immediate intervention by the healthcare team, which may include moving the mother into a knee-chest position or performing a cesarean section. Therefore, the priority action for the nurse is to ensure prompt medical intervention to protect the well-being of both the mother and the baby.
The nurse is explaining how a newly delivered baby initiates respiration. Which statement explains this process?
- A. Chemical thermal and mechanical factors
- B. Increase of po2 and decreased pco2
- C. Continued function of foramen ovale
- D. Drying off the infant
Correct Answer: A
Rationale: The correct statement explaining how a newly delivered baby initiates respiration is "Chemical thermal and mechanical factors." When a baby is born, various factors come into play to stimulate the baby's first breath. Chemically, the baby senses a decrease in oxygen and an increase in carbon dioxide levels, triggering the respiratory centers in the brain to start the breathing process. Thermally, exposure to the cooler air outside the womb stimulates the baby's skin receptors, encouraging the baby to take a breath. Mechanically, the pressure changes during delivery and the physical stimulation of the baby's face and body also play a role in initiating respiration. Overall, it is the combined effect of these chemical, thermal, and mechanical factors that help a newly delivered baby begin breathing independently.
The nurse is seeing a 17-year-old female in the clinic for complaints of acne. The nurse plans on taking advantage of this teachable moment with the teen. Which topics will the nurse include in the teen's teaching plan?
- A. Smoking habits, folic acid intake, and heart disease
- B. Hyperlipidemia, distracted driving, and menstrual history
- C. Sexual activity, contraception, and screening for violence
- D. Optimum weight, hypothyroidism, and sexually transmitted diseases
Correct Answer: D
Rationale: The most appropriate topics for the nurse to include in the teaching plan for the 17-year-old female with acne are optimum weight, hypothyroidism, and sexually transmitted diseases. Acne can be influenced by hormonal changes, which can be impacted by weight, thyroid function, and hormonal fluctuations related to sexual health. Educating the teen about these topics can help her understand potential contributing factors to her acne and empower her to make informed decisions about her health and lifestyle. It is important to address issues that are relevant to the teen's current health concerns while also providing valuable information for her overall well-being.
A patient is taking oral contraceptives and asks whether they will still be effective if she has diarrhea. What should the nurse respond?
- A. Oral contraceptives will still work if taken with food.
- B. Oral contraceptives may be less effective during diarrhea due to absorption issues.
- C. Oral contraceptives need to be stopped for 7 days when experiencing diarrhea.
- D. Oral contraceptives will be more effective during diarrhea due to faster metabolism.
Correct Answer: B
Rationale: Diarrhea can reduce the absorption of oral contraceptives, potentially making them less effective. Choice A is incorrect because food does not always affect oral contraceptive absorption. Choice C is incorrect because there is no need to stop the contraceptives, but additional methods may be recommended during diarrhea. Choice D is incorrect because diarrhea does not increase the effectiveness of oral contraceptives.