Nokea
The home health nurse visits a client who is 6 days postdelivery. The client appears sad, weeps frequently, and states, 'I don 't know what is wrong with me. I feel terrible. I should be happy, but I 'm not. ' Which of the following nursing diagnoses is appropriate for this client?
- A. Suicidal thoughts related to psychotic ideations.
- B. Post-trauma response related to traumatic delivery.
- C. Ineffective individual coping related to hormonal shifts.
- D. Spiritual distress related to immature belief systems.
Correct Answer: C
Rationale: The client 's symptoms suggest ineffective coping due to hormonal shifts commonly experienced during the postpartum period, possibly indicating postpartum blues.
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A postoperative cesarean section woman is to receive morphine 4 mg q 3 -4 h subcutaneously for pain. The morphine is available on the unit in premeasured syringes 10 mg/1 mL. Each time the nurse administers the medication, how many milliliters (mL) of morphine will be wasted? Calculate to the nearest tenth.
- A. 0.4 mL
- B. 0.6 mL
- C. 0.8 mL
- D. 1.0 mL
Correct Answer: B
Rationale: The nurse needs to administer 4 mg, and the syringe has 10 mg per 1 mL. Therefore, 4 mg will require 0.4 mL, and 0.6 mL will be wasted.
The nurse suspects that her postpartum client is experiencing hemorrhagic shock. Which observation indicates or would confirm this diagnosis?
- A. Absence of cyanosis in the buccal mucosa
- B. Cool, dry skin
- C. Calm mental status
- D. Urinary output of at least 30 ml/hr
Correct Answer: D
Rationale: Hemorrhagic shock is characterized by inadequate tissue perfusion due to severe blood loss, leading to decreased circulating volume. The body's compensatory mechanisms kick in to maintain blood pressure, causing the peripheral blood vessels to constrict. This constriction can lead to cool, clammy, and pale skin as the body shunts blood away from the skin's surface to the vital organs. The skin may also feel cool to the touch due to reduced perfusion. This observation is significant in indicating hemorrhagic shock because it signifies the body's response to the insufficient circulating volume and the need to prioritize perfusion to essential organs.
The nurse takes a newborn to a primipara for a feeding. The mother holds the baby en face, strokes his cheek, and states that this is the first newborn she has ever held. Which of the following nursing assessments is most appropriate?
- A. Positive bonding and client needs little teaching.
- B. Positive bonding but teaching related to newborn care is needed.
- C. Poor bonding and referral to a child abuse agency is essential.
- D. Poor bonding but there is potential for positive mothering.
Correct Answer: B
Rationale: The mother is engaging with the baby, indicating positive bonding, but further teaching on newborn care is still necessary.
What symptom differentiates baby blues from PPD?
- A. Baby blues last longer than 14 days.
- B. Baby blues cause hallucinations.
- C. Baby blues occur in the first few days of the postpartum period.
- D. Baby blues are treated with inpatient therapy.
Correct Answer: C
Rationale: Baby blues are typically short-lived occurring in the first few days postpartum and resolve without the need for treatment.
What would a steady trickle of bright red blood from the vagina in the presence of a firm fundus suggest to the nurse?
- A. Uterine atony
- B. Lacerations of the genital tract
- C. Perineal hematoma
- D. Infection of the uterus
Correct Answer: A
Rationale: The steady trickle of bright red blood from the vagina in the presence of a firm fundus suggests uterine atony. Uterine atony is a condition where the uterus fails to contract effectively after childbirth, resulting in postpartum hemorrhage. The firm fundus indicates that the uterus is not properly contracting to control bleeding, leading to the continuous flow of blood from the vagina. Prompt intervention is crucial to manage uterine atony and prevent further complications such as excessive blood loss.