Nokea
The full-term pregnant client presents with bright red vaginal bleeding and intense abdominal pain. Her BP is 150/96 mm Hg, and her pulse is 109 bpm. The nurse should immediately implement interventions for which possible complication?
- A. Placenta previa
- B. Placental abruption
- C. Bloody show
- D. Succenturiate placenta
Correct Answer: B
Rationale: The nurse should immediately implement interventions for placental abruption. This occurs when the placenta separates from the uterine wall before the birth of the fetus. It is commonly associated with preeclampsia. Placenta previa is marked by painless vaginal bleeding. Bloody show is a normal physiological sign associated with normal labor progression and is marked by bloody, mucuslike consistency. Succenturiate placenta is the presence of one or more accessory lobes that develop on the placenta with vascular connections of fetal origin.
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The nurse is educating the postpartum client. Which prevention strategies for postpartum depression should the nurse include? Select all that apply.
- A. Attend a support group that has other postpartum women.
- B. Use the baby’s nap time to complete household chores.
- C. Keep a journal of feelings during the postpartum period.
- D. Call the HCP if feelings of sadness do not subside quickly.
- E. Develop a daily schedule of activities, and follow the plan.
Correct Answer: A,C,D,E
Rationale: A postpartum support group can be a place where realistic information about postpartum depression can be discussed and symptoms recognized. Fatigue is a major concern for all postpartum women. Clients should be encouraged to nap when their infant is napping rather than using that time for other activities. Keeping a journal can be emotionally cathartic and can help prevent postpartum depression. Postpartum mothers should be encouraged to call their HCPs if symptoms of postpartum depression, such as feelings of sadness, do not subside quickly or if the symptoms become severe. Structuring activity with a schedule helps counteract inertia that comes with feeling sad or unsettled.
The oncoming shift nurse assesses the fundus of the postpartum client 6 hours after a vaginal birth and finds that it is firm. When the nurse then assists the client out of bed for the first time, blood begins to run down the client’s leg. Which action by the nurse in response to the client’s bleeding is correct?
- A. Explain that extra bleeding can occur with initial standing
- B. Immediately assist the client back into bed
- C. Push the emergency call light in the room
- D. Call the HCP to report this increased bleeding
Correct Answer: A
Rationale: Lochia normally pools in the vagina when the postpartum client remains in a recumbent position for any length of time. When the client then stands, gravity causes the blood to flow out. As long as the nurse knows the fundus is firm and not bleeding, a simple explanation to the client is all that is required. There is no reason to return the client to bed; the fundus is firm. There is no reason to push the emergency call light. Increased bleeding is an expected response when standing for the first time. There is no reason to call the HCP.
The 29-weeks-pregnant client presents to triage with decreased fetal movement. Her initial BP is 140/90 mm Hg. She states she “doesn’t feel well” and her vision is “blurry.” Additional assessment findings include: normal reflexes, +2 proteinuria, trace pedal edema, and puffy face and hands. What is the most important information that the nurse should obtain from the client’s prenatal record?
- A. Depressed liver enzymes
- B. BP at her first prenatal visit
- C. Urine dipstick from last visit
- D. The pattern of weight gain
Correct Answer: B
Rationale: The pregnant client with a BP that is greater than 140/90 mm Hg with the presence of proteinuria may have preeclampsia. New-onset hypertension is associated with preeclampsia. Generalized vasospasm in preeclampsia would result in reduced blood flow to the liver and elevated, not depressed, liver enzymes. The urine dip from the last visit should be reviewed but is not the most important to review because the significant information is the client’s elevated BP. The weight gain pattern should be reviewed but is not the most important to review because the significant information is the client’s elevated BP.
The nurse caring for the postpartum client who is 15 years old is concerned about this client’s ability to parent a newborn. Which behavior is characteristic of the developmental level of the 15-year-old that justifies the nurse’s concern?
- A. Developing autonomy
- B. Follows rules established by others
- C. Career oriented
- D. Egocentric
Correct Answer: D
Rationale: The development of autonomy is a developmental task of toddlerhood. School-age children are motivated to follow rules established by others. Adult women are concerned about the effect of childbearing on careers. Although it is biologically possible for the adolescent female to become a parent, her egocentricity and concrete thinking interfere with her ability to parent effectively. Because of this normal development, the adolescent may inadvertently neglect her child.
The pregnant client is experiencing low back pain. After determining that the client is not in labor, the nurse instructs the client to perform which exercises to increase comfort and decrease the incidence of the low back pain? Select all that apply.
- A. Kegel exercises
- B. Pelvic tilt exercises
- C. Leg raises
- D. Back stretch
- E. Stepping
Correct Answer: B,C,D
Rationale: Pelvic tilt exercises strengthen and stretch the abdominal and back muscles to relieve pain. Leg raises strengthen and stretch leg and abdominal muscles to relieve pain. Back stretch relieves pain from the back muscles caused by lordosis. Kegel exercises strengthen the pubococcygeal muscle, decreasing urinary leakage, but do not relieve back pain. Stepping provides aerobic exercise, which is good for circulation but is not recommended to decrease low back pain.