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A nurse is caring for a client who experienced a vaginal delivery 12 hr ago. When palpating the client's abdomen, at which of the following positions should the nurse expect to find the uterine fundus?
- A. At the level of the umbilicus
- B. 2 cm above the umbilicus
- C. One fingerbreadth above the symphysis pubis
- D. To the right of the umbilicus
Correct Answer: C
Rationale: After a vaginal delivery, the uterus typically undergoes involution, which is the process of the uterus returning to its pre-pregnancy size and position. At 12 hours postpartum, the uterine fundus should be palpated approximately one fingerbreadth above the symphysis pubis. This position indicates proper contraction of the uterus and helps prevent postpartum hemorrhage. As time progresses, the uterine fundus will gradually descend back into the pelvis.
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A nurse on a postpartum unit is receiving change-of-shift report for four clients. Which of the following.....
- A. A client who gave a birth 1 day ago and needs Rh˳(D) immune globulin.
- B. A client who gave a birth 3 days ago and reports breath fullness.
- C. A client who gave a birth 12 hr. ago and reports and increase in urinary output.
- D. A client who gave a birth 8 hr. ago and is saturating a perineal pad every hour.
Correct Answer: B
Rationale: The client who gave birth 3 days ago and reports breath fullness is showing signs of potential postpartum complications, such as a pulmonary embolism. Pulmonary embolism is a serious condition that can occur postpartum due to blood clot formation. Symptoms like breath fullness, chest pain, and shortness of breath should never be ignored in postpartum clients. This client requires immediate assessment and intervention to prevent further complications. The other options are concerning but do not indicate as urgent of a situation as breath fullness, which could be a life-threatening issue.
The nurse is monitoring a laboring client with oxytocin infusion. What finding requires immediate intervention?
- A. Contractions lasting 60 seconds.
- B. Contractions every 2 minutes.
- C. Fetal heart rate of 100 beats/minute.
- D. Client reports back pain.
Correct Answer: C
Rationale: A fetal heart rate of 100 bpm indicates bradycardia, requiring immediate intervention to ensure fetal well-being.
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 gestational hypertension. What symptom should be reported immediately?
- A. Headache unrelieved by acetaminophen.
- B. Slight swelling of the hands.
- C. Mild nausea after eating.
- D. Fatigue at the end of the day.
Correct Answer: A
Rationale: Headache unrelieved by medication may indicate worsening gestational hypertension or preeclampsia.
The woman with the lowest risk for sexually trans-
- A. Red swollen area around distal suture repair of mitted pelvic inflammatory disease is one who uses episiotomy site which of the following?
- B. Oral contraceptives
- C. A barrier method of contraception
- D. An intrauterine device for contraception
Correct Answer: C
Rationale: The lowest risk for sexually transmitted pelvic inflammatory disease is associated with using a barrier method of contraception, such as condoms. Barrier methods create a physical barrier that helps prevent the exchange of bodily fluids, reducing the risk of transmission of sexually transmitted infections, including pelvic inflammatory disease. Oral contraceptives, intrauterine devices, and birth control patches do not provide the same level of protection against sexually transmitted infections as barrier methods like condoms.