Nokea
A client is experiencing uterine atony after delivery. What is the nurse's first action?
- A. Massage the fundus until firm.
- B. Increase IV fluid rate.
- C. Notify the healthcare provider.
- D. Administer prescribed oxytocin.
Correct Answer: A
Rationale: Fundal massage stimulates uterine contraction and is the initial response to uterine atony to prevent hemorrhage.
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Mother in late middle age who is certain she is not pregnant tells
the nurse during an office visit she has urinary problems as well as
sensation of bearing down and of something in the vagina. The nurse
should realize that the client is most likely suffering from:
- A. Uterine prolapse
- B. Cystocele/rectocele
- C. Urinary tract infection (UTI)
- D. Endometriosis
Correct Answer: B
Rationale: A cystocele/rectocele occurs when the supportive tissue between a woman's bladder and vaginal wall weakens, allowing the bladder to bulge into the vagina. This can lead to urinary problems such as difficulty emptying the bladder completely, frequent urination, and urinary incontinence. The fact that the mother is in late middle age and certain she is not pregnant, combined with her urinary problems, suggests that she may be experiencing symptoms of a cystocele/rectocele. It is important for the nurse to further assess the client's symptoms and provide appropriate education and treatment options.
A client comes to the labor and delivery with polyhydramnios. She was admitted and her membrane ruptures is clear and odorless, but the fetal heart monitor indicate bradycardia and variable decelerations. What should action should be taken next?
- A. Perform vaginal exam (lot of fluid, check to see where baby is)
- B. High fowler position
- C. Warm saline soak vaginal
- D. Perform Leopold maneuver
Correct Answer: A
Rationale: In this scenario, with the presence of polyhydramnios and clear, odorless amniotic fluid, the fetal heart monitor indicating bradycardia and variable decelerations indicates a potential umbilical cord compression due to excessive amniotic fluid volume. It is crucial to perform a vaginal exam promptly as this can help assess the position of the baby and determine if there is a cord prolapse or any other complications that may be affecting the fetal heart rate. The baby's position needs to be identified quickly to address potential issues and ensure a safe delivery process.
A male infant delivered at 28 weeks gestation weighs 2 pounds, 12 ounces. When performing an assessment, the nurse would probably observe:
- A. Wide, staring eye
- B. Transparent, red skin
- C. An absence of lanugo
- D. A scrotum with descended testicles
Correct Answer: B
Rationale: A male infant delivered at 28 weeks gestation, as described, would likely have very underdeveloped skin due to the premature birth. The premature skin is often transparent, allowing the prominent blood vessels underneath to be visible, and may also have a reddish hue due to the skin's immaturity. This characteristic appearance is a common finding in premature infants and is a result of their skin being thinner and more fragile than that of full-term infants. The other options, such as a wide, staring eye, an absence of lanugo, and a scrotum with descended testicles, are not specifically associated with premature birth and are not likely to be observed in this scenario.
Early PPH is defined as blood loss greater than ____ 24h after delivery
- A. 500 mL 24h after normal delivery
- B. 1000 48h after c/s (lat
- C. 1500 mL after 48hr
- D. 750 mL after 24h vaginal delivery
Correct Answer: D
Rationale: Early postpartum hemorrhage (PPH) is defined as blood loss greater than 500 mL within the first 24 hours after vaginal delivery. This definition is crucial because it helps healthcare providers identify and promptly address any excessive bleeding that may occur in the immediate postpartum period. Monitoring postpartum bleeding is essential to prevent complications related to PPH, such as maternal anemia, hypovolemic shock, and even maternal death. By knowing the definition of early PPH, healthcare providers can take timely interventions to manage and treat postpartum hemorrhage effectively.
The nurse is caring for a client with suspected placenta previa. What is the priority nursing intervention?
- A. Perform a sterile vaginal examination.
- B. Monitor fetal heart rate and maternal vital signs.
- C. Administer oxytocin to stop the bleeding.
- D. Encourage the client to ambulate.
Correct Answer: B
Rationale: Monitoring maternal and fetal well-being is critical in cases of placenta previa to detect complications.