Nokea
The nurse is admitting a 38-year-old patient to triage in early labor with ruptured membranes. Her history includes a previous vaginal delivery 4 years ago and the presence of a uterine fibroid. What interventions are appropriate based on the hemorrhage risk for this patient?
- A. The patient is a moderate hemorrhage risk, so a type and screen should be ordered.
- B. The patient is a high hemorrhage risk, so 4 units of packed red blood cells should be ordered.
- C. The patient is a low hemorrhage risk, so a hold tube should be drawn.
- D. The patient is a moderate hemorrhage risk, but blood is not drawn at this time.
Correct Answer: A
Rationale: Since the patient has a previous history of delivery and uterine fibroids, she is considered at moderate hemorrhage risk and a type and screen should be ordered.
You may also like to solve these questions
The nurse develops a plan to increase a patient’s milk supply. What is an intervention they can implement?
- A. Pump between nursing sessions.
- B. Nurse every 6 hours.
- C. Keep newborn in bassinet between sessions.
- D. Offer a pacifier when newborn cries.
Correct Answer: A
Rationale: Pumping between nursing sessions can increase milk supply.
Which of the following nursing interventions would be appropriate for the nurse to perform to achieve the client care goal: The client will not develop postpartum thrombophlebitis?
- A. Encourage early ambulation.
- B. Promote oral fluid intake.
- C. Massage the legs of the client twice daily.
- D. Provide the client with high-fiber foods.
Correct Answer: A
Rationale: Early ambulation promotes circulation and reduces the risk of thrombophlebitis after delivery.
When referring to the 4 T 's of PPH, what does tissue refer to?
- A. Placental tissue or membranes are retained.
- B. Tissue of the perineum is torn.
- C. Tissue of the uterus is torn.
- D. Tissue is not perfused.
Correct Answer: A
Rationale: Retained placental tissue or membranes can cause postpartum hemorrhage (PPH) by preventing the uterus from contracting properly.
The nurse develops a plan to increase a patient’s milk supply. What is an intervention they can implement?
- A. Pump between nursing sessions.
- B. Nurse every 6 hours.
- C. Keep newborn in bassinet between sessions.
- D. Offer a pacifier when newborn cries.
Correct Answer: A
Rationale: The correct answer is A: Pump between nursing sessions. This intervention helps stimulate milk production by emptying the breasts more frequently. Pumping increases demand for milk, signaling the body to produce more. Nursing every 6 hours (B) reduces milk supply due to less frequent stimulation. Keeping newborn in bassinet (C) limits nursing opportunities. Offering a pacifier (D) may decrease milk supply by reducing nursing frequency. Therefore, option A is the most effective intervention to increase milk supply.
Choose the best independent nursing action to aid episiotomy healing in the woman who is 24 hours postpartum.
- A. Apply antibiotic cream to the area three times each day.
- B. Squirt warm water over the perineum after voiding or stooling.
- C. Maintain cold packs to the area at all times for the first 3 days.
- D. Check the leukocyte level daily and report changes.
Correct Answer: B
Rationale: Squatting warm water over the perineum after voiding or stooling helps to soothe and cleanse the area, promoting healing.