Nokea
The nurse explains to the group that frequent urination during early pregnancy usually subsides at which time?
- A. When the placenta is fully developed
- B. When fetal kidneys begin to function
- C. When the uterus rises into the abdominal cavity
- D. When the hormonal balance is reestablished
Correct Answer: C
Rationale: Frequent urination subsides in the second trimester as the uterus rises into the abdominal cavity, reducing bladder pressure.
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Two hours after the client’s vaginal delivery, she reports feeling “several large, warm gushes of fluid” from her vagina. The nurse assesses the client’s perineum and finds a large pool of blood on the client’s bed. Which nursing action is priority?
- A. Encourage the client to ambulate to the bathroom in order to empty her bladder.
- B. Place two hands on the uterine fundus and prepare to vigorously massage the uterus.
- C. Reassure the client that heavy bleeding is expected in the first few hours postpartum.
- D. Support the lower uterine segment with one hand and assess the fundus with the other.
Correct Answer: D
Rationale: A full bladder may displace the uterus, causing increased bleeding. However, a more complete assessment must be performed prior to getting the client out of bed to prevent increased bleeding and syncope. Vigorously massaging the uterus may result in inversion of the uterus. The client should not simply be reassured that heavy bleeding is expected because further assessment is necessary before concluding that the client’s blood loss is WNL. The nurse’s first action should be to support the lower uterine segment and to assess the fundus. Increased bleeding will occur if soft or “boggy.” Failing to support the lower uterine segment may result in inversion of the uterus.
Which position should the nurse recommend for early labor?
- A. Lying flat on the back
- B. Walking or standing
- C. Sitting upright
- D. Kneeling on all fours
Correct Answer: B
Rationale: Walking or standing in early labor promotes progress and comfort, unlike lying flat, which may slow labor.
The nurse is assessing the postpartum client, who is 5 hours postdelivery. Initially, the nurse is unable to palpate the client’s uterine fundus. Prioritize the nurse’s actions to locate the client’s fundus by placing each step in the correct sequence.
- A. Place the side of one hand just above the client’s symphysis pubis.
- B. Press deeply into the abdomen.
- C. Place the other hand at the level of the umbilicus.
- D. Massage the abdomen in a circular motion.
- E. Position the client in the supine position.
- F. If the fundus is not felt, move the upper hand lower on the abdomen and repeat the massage.
Correct Answer: E,A,C,B,D,F
Rationale: Position the client in supine so the height of the uterus is not influenced by an elevated position. Place the side of one hand just above the client’s symphysis pubis. This supports the lower uterine segment and prevents the inadvertent inversion of the uterus during palpation. Place the other hand at the level of the umbilicus. This is the expected location of the uterine fundus on the day of delivery. Press deeply into the abdomen to allow the massage to reach the fundus. Massage the abdomen in a circular motion. This massage should stimulate the uterus to contract and allow location of the fundus to be determined. If the fundus is not felt, move the upper hand lower on the abdomen and repeat the massage. Involution could potentially be occurring more rapidly than expected if the client is breastfeeding and/or had an uncomplicated labor and birth.
The postpartum client suffered a fourth-degree perineal laceration during her vaginal birth. Which interventions should the nurse add to the client’s plan of care? Select all that apply.
- A. Limit ambulation to bathroom privileges only.
- B. Decrease fluid intake to 1000 mL every 24 hours.
- C. Instruct the client on a high-fiber diet.
- D. Monitor the uterus for firmness every 2 hours.
- E. Give pm prescribed stool softeners in the am. and at h.s.
Correct Answer: C,E
Rationale: Activity should be increased, not decreased, to reduce the potential for constipation. Fluids should be increased, not decreased, to reduce the potential for dehydration and constipation. The client with a fourth-degree perineal laceration should be instructed to increase dietary fiber to help maintain bowel continence and decrease perineal trauma from constipation. A perineal laceration will not affect the condition of the uterus; there is no need to increase uterine monitoring. The client with a fourth-degree perineal laceration should be given a stool softener bid to help maintain bowel continence and decrease perineal trauma from constipation.
The pregnant client has an abnormal 1-hour glucose screen and completes a 3-hour, 100-g oral glucose tolerance test (OGTT). Which test results should the nurse interpret as being abnormal?
- A. Fasting blood glucose = 104 mg/dL
- B. 1-hour = 179 mg/dL
- C. 2-hour = 146 mg/dL
- D. 3-hour = 129 mg/dL
Correct Answer: A
Rationale: The fasting blood glucose of 104 mg/dL is abnormal for the OGTT; normal is 95 mg/dL or lower. A 1-hour OGTT value of 179 mg/dL is normal; normal is 180 mg/dL or lower. The 2-hour OGTT value of 146 mg/dL is normal; an abnormal value is 155 mg/dL or higher. The 3-hour OGTT value of 129 mg/dL is normal; an abnormal value is 140 mg/dL or higher.