Nokea
The nurse correctly explains that the bleeding is the result of sloughing of which structure?
- A. Endometrium
- B. Myometrium
- C. Epimetrium
- D. None of the above
Correct Answer: A
Rationale: Menstrual bleeding occurs due to the sloughing of the endometrium, the inner lining of the uterus, when pregnancy does not occur.
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The postpartum client is being admitted for mastitis. The nurse should prepare the client for which interventions? Select all that apply.
- A. Walking at least four times in 24 hours
- B. Receiving a prescribed oral antibiotic
- C. Applying warm packs to the breasts
- D. Getting a prescribed anti-inflammatory drug
- E. Limiting oral fluid intake to 1000 mL per day
- F. Emptying the milk from her breasts frequently
Correct Answer: B,C,D,F
Rationale: Rest is important to promote healing. Bed rest may be initially prescribed for 24 hours. Treatment for mastitis includes administration of antibiotics to treat the infection. Application of warm packs decreases pain and promotes milk flow and breast emptying. Treatment for mastitis includes anti-inflammatory medications to treat fever and decrease breast inflammation. Increasing fluid intake to at least 2 to 3 liters is recommended, not limiting intake. If the breasts continue to be emptied by either breastfeeding or pumping, the duration of symptoms and the incidence of a breast abscess are decreased.
The nurse instructs the client to report which newborn symptom immediately?
- A. Mild jaundice on day 3
- B. Inability to suck or feed
- C. Occasional sneezing
- D. Soft spot on head
Correct Answer: B
Rationale: Inability to suck or feed is a serious symptom that may indicate neurological or health issues, requiring immediate reporting.
The nurse’s laboring client is being electronically monitored during her labor. The baseline FHR throughout the labor has been in the 130s. In the last 2 hours, the baseline has decreased to the 100s. How should the nurse document this FHR?
- A. Tachycardia
- B. Bradycardia
- C. Late deceleration
- D. Within normal limits
Correct Answer: B
Rationale: An FHR baseline less than 110 is classified as bradycardia. Tachycardia occurs when the baseline is greater than 160 bpm. A prolonged deceleration is defined as a change from the baseline FHR that occurs for 2 to 10 minutes before returning to baseline. A late deceleration is a gradual decrease and return of the FHR to baseline, associated with a uterine contraction. A decrease to the 100s is not within the normal range. The normal FHR is 120 to 160 bpm.
On the basis of this finding, the nurse can assume that the client is at least how many months' pregnant?
- A. 5 months
- B. 6 months
- C. 7 months
- D. 8 months
Correct Answer: A
Rationale: Ballottement, the rebound of the fetus when the cervix is tapped, is typically detectable around 4-5 months, indicating at least 5 months' gestation.
The nurse just administered butorphanol tartrate as prescribed to the client in active labor. Following administration of butorphanol tartrate, what is the nurse’s most important action to help prevent side effects?
- A. Assess the client’s bladder for distention
- B. Place the client on seizure precautions
- C. Assess the client’s body for itchy rash
- D. Evaluate her vital signs and pulse oximetry
Correct Answer: D
Rationale: Evaluating maternal VS and pulse oximetry would determine changes in respiratory and cardiac status. Respiratory depression in both the mother and fetus can occur with butorphanol tartrate (Stadol). Although bladder distention is a possible side effect of butorphanol tartrate, it is not common and is not the most important assessment. Seizures are not a potential side effect of butorphanol tartrate. An itchy rash is not a potential side effect of butorphanol tartrate.