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The nurse is assessing a postpartum client who delivered 2 hours ago. What finding requires immediate action?
- A. Fundus firm and midline.
- B. Lochia rubra with small clots.
- C. Boggy fundus above the umbilicus.
- D. Client reports perineal discomfort.
Correct Answer: C
Rationale: A boggy fundus indicates uterine atony, increasing the risk of hemorrhage.
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What is the first action for a mother experiencing excessive bleeding two hours postpartum?
- A. Monitor blood pressure and heart rate
- B. Perform uterine massage to stimulate contractions
- C. Prepare for a possible blood transfusion
- D. Notify the healthcare provider immediately
Correct Answer: A
Rationale: Uterine massage stimulates contractions, which can reduce postpartum bleeding.
The nurse is monitoring a client with severe preeclampsia. What assessment finding requires immediate intervention?
- A. Blood pressure of 150/90 mmHg.
- B. Urine output of 25 mL/hr.
- C. Headache relieved by acetaminophen.
- D. Deep tendon reflexes +2.
Correct Answer: B
Rationale: Oliguria (urine output <30 mL/hr) may indicate worsening renal function or severe complications in preeclampsia.
A nurse is teaching a prenatal class regarding false labor. Which of the following information should the nurse include?
- A. "Your contraction will become more intense when walking"
- B. "You will have dilation and effacement of the cervix"
- C. You will have bloody show"
- D. "Your contraction will become temporally regular"
Correct Answer: D
Rationale: False labor, also known as Braxton Hicks contractions, are contractions that are irregular and do not lead to cervical dilation and effacement, unlike true labor contractions. During false labor, contractions may feel intense when walking, but they do not become progressively more intense over time, as is seen in true labor. Additionally, false labor contractions do not typically result in bloody show, which is a sign of impending true labor. Therefore, the correct information to include regarding false labor is that contractions will remain temporarily irregular in nature.
For which conditions is the lactational amenorrhea method of birth control effective?
- A. Being less than 6 months postpartum.
- B. Being amenorrheic since delivery of the baby.
- C. Supplementing with formula no more than once per day.
- D. Losing less than 10% of weight since delivery.
Correct Answer: A
Rationale: Lactational amenorrhea is effective only within 6 months postpartum if exclusively breastfeeding.
The nurse is reviewing a copy of the U.S. Surgeon General's Report, Healthy People 2020. Which nursing action best reflects the nurse fostering this health care agenda?
- A. The nurse signs up for classes to obtain an advanced degree in nursing.
- B. The nurse volunteers at a local health care clinic providing free vaccinations for low-income populations.
- C. The nurse performs an in-service on basic hospital equipment for student nurses.
- D. The nurse compiles nursing articles on evidence-based practices in nursing to present at a hospital training seminar.
Correct Answer: B
Rationale: Healthy People 2020 is a comprehensive health promotion and disease prevention agenda that is working toward improving the quantity and quality of life for all Americans.