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The nurse is assessing a client at her postpartum checkup 6 weeks after a vaginal delivery. The mother is bottle feeding her baby. Which client finding indicates a problem at this time?
- A. Firm fundus at the symphysis.
- B. White, thick vaginal discharge.
- C. Striae that are silver in color.
- D. Soft breasts without milk.
Correct Answer: B
Rationale: White, thick vaginal discharge at 6 weeks suggests an infection, as lochia should be minimal or absent by this time.
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A laboring client smiles pleasantly at the nurse when asked simple questions. The client speaks no English and the interpreter is busy with an emergency situation. At her last vaginal examination, the client was 5 cm dilated, 100% effaced, and at 0 station. While working with this client, which of the following responses indicates that the client may be approaching delivery?
- A. The fetal monitor strip shows late decelerations.
- B. The client begins to speak to her family in her native language.
- C. The fetal monitor strip shows early decelerations.
- D. The client's facial expressions become animated.
Correct Answer: D
Rationale: Animated facial expressions (e.g., grimacing, distress) may indicate transition or second-stage labor, suggesting imminent delivery. Late decelerations indicate fetal distress, speaking to family is nonspecific, and early decelerations are normal.
An adolescent primiparous client at 24 hours postpartum tells the nurse that she and her baby will be living with her boyfriend's parents so that she can finish high school and go on to college. The client's boyfriend and parents have been supportive of the client and neonate. Which of the following is an appropriate nursing diagnosis at this time?
- A. Anxiety related to return to high school and peer pressure.
- B. Ineffective coping related to inability to view motherhood realistically.
- C. Readiness for enhanced family coping, related to the addition of a new family member.
- D. Deficient knowledge related to the financial and emotional costs of childrearing.
Correct Answer: C
Rationale: The supportive environment suggests readiness for enhanced family coping, which is appropriate given the positive family dynamics.
A primiparous client who underwent a cesarean delivery 30 minutes ago is to receive Rho(D) immune globulin (RhoGAM). The nurse should administer the medication within which of the following time frames after delivery?
- A. 8 hours.
- B. 24 hours.
- C. 72 hours.
- D. 96 hours.
Correct Answer: C
Rationale: RhoGAM should be administered within 72 hours postpartum to prevent Rh sensitization.
A nurse and a nursing assistant are caring for clients in a labor and delivery unit. Which task should the registered nurse assign to the nursing assistant?
- A. Perform a fundal check on a 2-day postpartum client.
- B. Remove a fetal monitor and assist a client to the bathroom.
- C. Give ibuprofen 800 mg by mouth to a newly delivered client.
- D. Teach a new mother how to bottle-feed her infant.
Correct Answer: B
Rationale: A nursing assistant can assist with mobility tasks like removing a fetal monitor and helping a client to the bathroom. Fundal checks, medication administration, and teaching require RN skills.
A 24-hour-old, full-term neonate is showing signs and possible signs. The nurse is assisting the physician with a lumbar puncture on this neonate. What should the nurse do to assist in this procedure? Select all that apply.
- A. Administer the I.V. antibiotic.
- B. Hold the neonate steady in the correct position.
- C. Ensure a patent airway.
- D. Maintain a sterile field.
- E. Obtain a serum glucose level.
Correct Answer: B,C,D
Rationale: Holding the neonate steady, ensuring a patent airway, and maintaining a sterile field are critical during a lumbar puncture to ensure safety and procedure success.