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The nurse is assessing a postpartum client. Which finding requires immediate intervention?
- A. Fundus firm and midline.
- B. Lochia rubra with large clots.
- C. Mild swelling in the perineal area.
- D. Breast tenderness on day 2 postpartum.
Correct Answer: B
Rationale: The correct answer is B because Lochia rubra with large clots could indicate excessive bleeding, which is a postpartum hemorrhage and requires immediate intervention to prevent further complications. A: Fundus firm and midline is a normal finding. C: Mild swelling in the perineal area is expected after childbirth. D: Breast tenderness on day 2 postpartum is a common finding due to milk production starting.
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Why would FAM not be appropriate for the nurse to recommend to a perimenopausal person?
- A. At that age, people do not have intercourse on a regular basis.
- B. They are married and do not need contraception.
- C. They have irregular menstrual periods.
- D. Pregnancy is not a concern when a person is perimenopausal.
Correct Answer: C
Rationale: The correct answer is C because perimenopausal individuals often have irregular menstrual periods, making FAM less reliable for tracking ovulation. Irregular periods can make it challenging to accurately predict fertile days. Choice A is incorrect because FAM is not solely for contraception but also for fertility awareness. Choice B is incorrect as FAM can still be used for tracking fertility even if contraception is not needed. Choice D is incorrect because while pregnancy risk decreases during perimenopause, it is not zero, and FAM can still be helpful for those who wish to avoid pregnancy.
Placental circulation is dependent on maternal circu- tions for preventing sudden infant death syndrome? lation. In which maternal circumstances is placental Select all that apply. circulation impeded? Select all that apply.
- A. Position newborns in the prone position to
- B. Hypotension
- C. Pre-eclampsia
- D. Avoid soft bedding or pillows in the newborn's
Correct Answer: B
Rationale: The correct answer is B: Hypotension. Hypotension in the mother can result in decreased blood flow to the placenta, affecting placental circulation and oxygen delivery to the fetus, increasing the risk of sudden infant death syndrome.
A: Positioning newborns in the prone position does not directly impede placental circulation.
C: Pre-eclampsia can affect placental circulation due to high blood pressure, but it is not the only maternal condition that can impede placental circulation.
D: Avoiding soft bedding or pillows in the newborn's crib is related to safe sleep practices but does not directly impede placental circulation.
What is the priority nursing care associated with oxytocin infusion?
- A. Monitoring uterine response (don't want it to ruptur
- C. Measuring urinary output
- D. Check cervical dilation
Correct Answer: A
Rationale: The correct answer is A because monitoring uterine response is crucial when administering oxytocin infusion to prevent uterine hyperstimulation and rupture. This involves assessing contraction frequency, duration, and strength. Measuring urinary output (choice C) is important for overall fluid balance but not directly related to oxytocin infusion. Checking cervical dilation (choice D) is not a priority when administering oxytocin. Choice B is incomplete.
A nurse is caring for newborn who is 1 hr. old and has a respiratory rate of 50/min, a heart rate of 130/min, and an auxiliary temperature of 36.1*C (97F). Which of the following actions should the nurse take?
- A. Give the newborn a warm bath.
- B. Apply a cap to the newborn head.
- C. Reposition the newborn.
- D. Obtain an oxygen saturation level
Correct Answer: C
Rationale: The correct action is to reposition the newborn. The vital signs provided indicate that the newborn may be experiencing cold stress, which can lead to hypothermia. Repositioning the newborn can help conserve heat and maintain a stable temperature. Giving a warm bath (choice A) may further decrease body temperature. Applying a cap (choice B) may help retain heat but does not address the underlying issue. Obtaining an oxygen saturation level (choice D) is not necessary based on the information provided.
A client at 36 weeks' gestation reports severe itching without a rash. What condition should the nurse suspect?
- A. Cholestasis of pregnancy.
- B. Preeclampsia.
- C. Gestational diabetes.
- D. Intrauterine growth restriction.
Correct Answer: A
Rationale: The correct answer is A: Cholestasis of pregnancy. Severe itching without a rash in a pregnant client at 36 weeks' gestation is often indicative of cholestasis of pregnancy, a liver condition that can occur during pregnancy. This condition is characterized by reduced bile flow, leading to the accumulation of bile acids in the blood, resulting in itching, especially on the palms and soles of the feet. Other choices (B) Preeclampsia, (C) Gestational diabetes, and (D) Intrauterine growth restriction are not typically associated with severe itching without a rash in the absence of other specific symptoms. Preeclampsia presents with hypertension and proteinuria, gestational diabetes with high blood sugar levels, and intrauterine growth restriction with poor fetal growth.