Nokea
The nurse has administered Benadryl (diphenhydramine) to a post-cesarean client who is experiencing side effects from the parenteral morphine sulfate that was administered 30 minutes earlier. Which of the following actions should the nurse perform following the administration of the drug?
- A. Monitor the urinary output hourly.
- B. Supervise while the woman holds her newborn.
- C. Position the woman slightly elevated on her left side.
- D. Ask any visitors to leave the room.
Correct Answer: B
Rationale: Supervision ensures safety due to potential sedation.
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The nurse is caring for a couple who are in the labor/delivery room immediately after the delivery of a dead baby who exhibited visible birth defects. Which of the following actions by the nurse is appropriate?
- A. Discourage the parents from naming the baby.
- B. Advise the parents that the baby's defects would be too upsetting for them to see.
- C. Transport the baby to the morgue as soon as possible.
- D. Give the parents a lock of the baby's hair and a copy of the footprint sheet.
Correct Answer: D
Rationale: Providing keepsakes helps with grieving.
What theory developed by Ramona Mercer focused on the process of becoming a mother?
- A. Maternal Role Attainment
- B. Postpartum Adapting
- C. Postpartum Maternal Change
- D. Maternal Encouragement
Correct Answer: A
Rationale: The correct answer is A: Maternal Role Attainment. Mercer's theory emphasizes the process through which a woman acquires the maternal role, including changes in behavior, attitudes, and values. Choice B, Postpartum Adapting, is vague and doesn't specifically address the process of becoming a mother. Choice C, Postpartum Maternal Change, is too general and lacks the focus on role attainment. Choice D, Maternal Encouragement, is not a theory developed by Ramona Mercer and does not capture the essence of the maternal role attainment process.
A mother, G4 P4004, is 15 minutes postpartum. Her baby weighed 4,595 grams at birth. For which of the following complications should the nurse monitor this client?
- A. Seizures.
- B. Hemorrhage.
- C. Infection.
- D. Thrombosis.
Correct Answer: B
Rationale: Macrosomic babies increase the risk of postpartum hemorrhage.
Which assessment finding 24 hours after vaginal birth would indicate a need for further intervention?
- A. Pain level 5 on scale of 0 to 10
- B. Saturated pad over a 2-hour period
- C. Urinary output of 500 mL in one voiding
- D. Uterine fundus 2 cm above the umbilicus
Correct Answer: B
Rationale: The correct answer is B because a saturated pad over a 2-hour period 24 hours after vaginal birth could indicate postpartum hemorrhage, a serious complication requiring immediate intervention. Excessive bleeding can lead to hypovolemic shock and endanger the mother's life. Monitoring and managing postpartum bleeding is crucial to prevent complications.
A: Pain level of 5 is subjective and may vary among individuals. It does not necessarily indicate a need for immediate intervention.
C: Urinary output of 500 mL in one voiding is within the normal range for postpartum women and does not suggest an immediate need for intervention.
D: Uterine fundus 2 cm above the umbilicus is within the expected range for 24 hours postpartum and does not indicate a need for immediate intervention.
A nurse on the postpartum unit is caring for two postoperative cesarean clients. One client had spinal anesthesia for the delivery and the other client had an epidural. Which of the following complications will the nurse monitor the spinal client for that the epidural client is much less high risk for?
- A. Pruritus.
- B. Nausea.
- C. Postural headache.
- D. Respiratory depression.
Correct Answer: C
Rationale: Spinal anesthesia increases the risk of postural headaches.