Nokea
The nurse and a nursing assistant are caring for clients in a birthing center. Which of the following tasks should the nurse delegate to the nursing assistant? Select all that apply.
- A. Removing a Foley catheter from a preeclamptic client.
- B. Assisting an active labor client with breathing and relaxation.
- C. Ambulating a postcesarean client to the bathroom.
- D. Calculating hourly I.V. totals for a preterm labor client.
- E. Intake and output catheterization for culture and sensitivity.
- F. Calling a report of normal findings to the health care provider.
- G. Removing lunch trays and documenting lunch intake.
Correct Answer: C,G
Rationale: Delegating ambulation and lunch tray removal is appropriate for a nursing assistant.
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The nurse on the night shift finds a multiparous client, 8 hours postpartum, drenched in perspiration. The client's temperature is 99°F (36.8°C), the pulse is 68 bpm, and the blood pressure is 120/80 mm Hg. Which of the following nursing diagnoses is a priority?
- A. Risk for infection (postpartum) related to birth trauma.
- B. Ineffective thermoregulation related to hormonal changes.
- C. Ineffective tissue perfusion: Renal related to the status of multiparity.
- D. Excess fluid volume related to normal postpartal diuresis.
Correct Answer: B
Rationale: Profuse sweating and normal vital signs suggest ineffective thermoregulation due to hormonal shifts, a common postpartum occurrence.
A client is considering the lactational amenorrhea method (LAM) for contraception. Which of the following conditions must be met for LAM to be effective?
- A. The client must be exclusively breastfeeding, amenorrheic, and less than 6 months postpartum.
- B. The client must be breastfeeding at least once daily and less than 12 months postpartum.
- C. The client must be amenorrheic and supplementing with formula.
- D. The client must be exclusively breastfeeding and have regular periods.
Correct Answer: A
Rationale: LAM is effective when the client is exclusively breastfeeding, amenorrheic, and less than 6 months postpartum, as these conditions suppress ovulation. The other options include factors that reduce its effectiveness, such as formula supplementation or regular periods.
The physician determines that outlet forceps are needed to assist in the delivery of a primigravid client in active labor with a large-for-gestational-size fetus. The nurse reinforces the physician's explanation for using forceps based on the understanding about which of the following concerning the location of the fetus?
- A. Fetal head at the pelvic outlet.
- B. Fetal head at the ischial spines.
- C. Fetal head above the pelvic brim.
- D. Fetal head in the false pelvis.
Correct Answer: A
Rationale: Outlet forceps are used when the fetal head is at the pelvic outlet, visible at the perineum, allowing safe assisted delivery. Higher fetal positions require different interventions.
A 29-year-old multigravida at 37 weeks' gestation is being treated for severe preeclampsia and has magnesium sulfate infusing at 3 g/hour. The nurse has determined the priority nursing diagnosis to be: risk for central nervous system injury related to hypertension, edema of cerebrum. To maintain safety for this client, the nurse should:
- A. Maintain continuous fetal monitoring.
- B. Encourage family members to remain at bedside.
- C. Assess reflexes, clonus, visual disturbances, and headache.
- D. Monitor maternal liver studies every 4 hours.
Correct Answer: C
Rationale: Monitoring signs of CNS irritability such as reflexes, clonus, visual disturbances, and headache helps detect worsening preeclampsia.
A multiparous client, 72 hours postpartum, reports a sudden gush of lochia rubra. The nurse should suspect:
- A. Normal involution.
- B. Uterine subinvolution.
- C. Cervical laceration.
- D. Retained placental fragments.
Correct Answer: D
Rationale: A sudden gush of lochia rubra after 72 hours suggests retained placental fragments, which can cause hemorrhage.