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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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People in extended families can live together for many reasons. What can the nurse do to provide the best care for a person living with an extended family?
- A. Assume the family is poor and needs information on financial assistance.
- B. Ask the person if they would like the family members to remain in the room during the exam.
- C. Set a limit on who is allowed in the room with the person regardless of the circumstances.
- D. Address the family first then the patient.
Correct Answer: B
Rationale: The correct answer is B because it respects the person's autonomy and preferences by asking if they want family members present during the exam. This approach ensures the person's comfort and privacy while also promoting family involvement in care. Choice A assumes financial need without evidence. Choice C limits family support. Choice D may neglect the person's immediate needs.
A nurse is reviewing a laboratory results for a client who is at 33 weeks of gestation and has preeclampsia. Which of the following laboratory results should the nurse report to the provider?
- A. BUN 35 mg/dL
- B. Hgb 15 mg/dL
- C. Bilirubin 0.6 mg/dL
- D. Hct 37%
Correct Answer: A
Rationale: The correct answer is A: BUN 35 mg/dL. In preeclampsia, elevated BUN levels indicate impaired kidney function, a serious complication. High BUN can lead to renal damage. Hgb, Hct, and Bilirubin levels are within normal ranges for pregnancy, so they do not indicate a critical issue. Reporting BUN level is crucial for monitoring kidney function and preventing further complications in preeclampsia.
The nurse is assessing a client in active labor with variable decelerations on the fetal monitor. What is the priority intervention?
- A. Increase oxytocin infusion.
- B. Reposition the client.
- C. Administer oxygen at 10 L/min.
- D. Perform a vaginal examination.
Correct Answer: B
Rationale: The correct answer is B: Reposition the client. Variable decelerations can indicate umbilical cord compression. Repositioning the client can help relieve the compression, improving fetal oxygenation. Increasing oxytocin (A) could worsen the situation. Administering oxygen (C) may be needed but repositioning is the priority. Performing a vaginal examination (D) is not indicated for variable decelerations.
A woman in labor reports a gush of fluid from her vagina. What is the nurse's first action?
- A. Check the fetal heart rate
- B. Assess the fluid for meconium staining
- C. Perform a sterile vaginal examination
- D. Notify the healthcare provider
Correct Answer: A
Rationale: The correct answer is A: Check the fetal heart rate. This is the first action to assess the well-being of the fetus after the reported fluid gush, ensuring fetal safety. Checking fetal heart rate is crucial in determining fetal distress. Assessing for meconium staining (B) is important but comes after confirming fetal well-being. Performing a sterile vaginal examination (C) may introduce infection and should be avoided without proper indications. Notifying the healthcare provider (D) is necessary but should follow initial assessment of fetal status.
The nurse is caring for a client in labor and is monitoring the fetal heart rate patterns. The nurse notes the presence of episodic accelerations on the electronic fetal monitor tracing. Which action is most appropriate?
- A. Notify the health care provider of the findings.
- B. Reposition the mother and check the monitor for changes in the fetal tracing.
- C. Take the mother's vital signs and tell the mother that bed rest is required to conserve oxygen.
- D. Document the findings and tell the mother that the pattern on the monitor indicates fetal well-being.
Correct Answer: D
Rationale: The correct answer is D: Document the findings and tell the mother that the pattern on the monitor indicates fetal well-being. This is the most appropriate action because episodic accelerations in fetal heart rate patterns are a reassuring sign of fetal well-being. By documenting the findings and informing the mother of this, the nurse can provide reassurance and promote a positive birthing experience.
Choice A is incorrect because notifying the health care provider is not necessary for this normal finding. Choice B is incorrect because repositioning the mother and checking the monitor for changes is not needed when episodic accelerations are present. Choice C is incorrect because taking the mother's vital signs and prescribing bed rest is unnecessary and not indicated based on the fetal heart rate pattern.