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The nurse is assessing the client 30 min later. How should the nurse interpret the findings? For each finding, click to specify whether the finding is unrelated to the diagnosis, an indication of potential improvement, or an indication of potential worsening condition.
- A. Fundus at level of umbilicus
- B. Cloudy urine
- C. Blood pressure 80/50 mm Hg
- D. Moderate lochia rubra
- E. Thready pulse
- F. Fundus firm to palpation
Correct Answer:
Rationale: Correct Answer:
Rationale:
- Fundus at the level of the umbilicus indicates proper involution of the uterus, a sign of potential improvement.
- Cloudy urine is unrelated to the diagnosis and may indicate a urinary tract infection.
- Blood pressure of 80/50 mm Hg is an indication of potential worsening condition, indicating hypotension.
- Moderate lochia rubra is a normal finding in the postpartum period.
- Thready pulse is an indication of potential worsening condition, suggesting poor perfusion.
- Fundus firm to palpation is a normal finding indicating proper uterine contraction and involution.
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Which of the following assessment findings requires Immediate follow-up? Select all that apply,
- A. Platelet count
- B. Vaginal bleeding
- C. HCT
- D. RBC Count
- E. Fetal heart rate
- F. hgb
- G. WBC Count
Correct Answer: B,C,E,F
Rationale: The correct answers are B, C, E, and F. Vaginal bleeding requires immediate follow-up to assess for potential complications. HCT, HGB, and WBC count are crucial for evaluating maternal health. Fetal heart rate is essential for monitoring fetal well-being. Platelet count and RBC count are important but not as urgent as the other findings.
A nurse is discussing fertility treatment options with a client and their partner. Which of the following nonpharmacological treatments should the nurse suggest?
- A. Use a lubricant during intercourse.
- B. Drink herbal tea two times daily.
- C. Maintain a healthy weight.
- D. Take daily hot baths.
Correct Answer: C
Rationale: The correct answer is C: Maintain a healthy weight. This is because maintaining a healthy weight is a crucial nonpharmacological factor that can positively impact fertility. Excess weight can disrupt hormonal balance and lead to ovulation issues in women and reduced sperm quality in men. A healthy weight can improve the chances of conception.
A: Using a lubricant during intercourse does not directly impact fertility and is not a recommended nonpharmacological treatment option.
B: Drinking herbal tea may have some health benefits, but there is no scientific evidence to support its effectiveness in improving fertility.
D: Taking hot baths can actually have a negative effect on sperm production in men due to the increased temperature in the genital area.
In summary, maintaining a healthy weight is the most appropriate nonpharmacological treatment option for improving fertility compared to the other choices provided.
A nurse is assessing a newborn who was born postterm. Which of the following findings should the nurse expect?
- A. Large deposits of subcutaneous fat
- B. Thin covering of fine hair on shoulders and back
- C. Nails extending over tips of fingers
- D. Pale, translucent skin
Correct Answer: C
Rationale: The correct answer is C: Nails extending over tips of fingers. Postterm newborns have longer nails due to their prolonged growth in utero. This is a common finding in babies born after 42 weeks gestation. Large deposits of subcutaneous fat (choice A) are typically seen in term or postterm newborns, not specific to postterm. Thin covering of fine hair on shoulders and back (choice B) is known as lanugo, which is present in premature infants, not postterm. Pale, translucent skin (choice D) is more common in premature infants, not postterm.
A nurse is planning care for a client who is 1 hr postpartum and has peripartum cardiomyopathy. Which of the following actions should the nurse plan to take?
- A. Obtain a prescription for misoprostol.
- B. Assess blood pressure twice daily.
- C. Restrict daily oral fluid intake.
- D. Administer an IV bolus of lactated Ringer's.
Correct Answer: B
Rationale: The correct answer is B: Assess blood pressure twice daily. Postpartum peripartum cardiomyopathy can lead to heart failure and hypertension. Monitoring blood pressure is crucial to detect any worsening of the condition promptly. Misoprostol is not indicated for this condition. Fluid restriction may be necessary in some cases, but oral fluid intake should not be restricted immediately postpartum. Administering IV bolus of lactated Ringer's is not specific to managing peripartum cardiomyopathy. Regular blood pressure monitoring is essential for early detection and management of complications.
Select the 3 findings that require immediate follow-up.
- A. Lateral deviation of the uterus
- B. Deep tendon reflexes 1+
- C. Pain rating of 3 on a scale of 0 to 10 (increased)
- D. Peripheral edema 2+ bilateral lower extremities
- E. Uterine tone soft
- F. Large amount of lochia rubra
- G. Blood pressure 136/86 mm Hg
Correct Answer: A,B,C
Rationale: The correct choices for immediate follow-up are A, B, and C. A lateral deviation of the uterus could indicate a possible complication like uterine atony or retained products of conception. Deep tendon reflexes of 1+ could suggest hyporeflexia or neurological issues. A pain rating of 3 on a scale of 0 to 10, especially if it has increased, may indicate worsening pain or a new issue. Choices D, E, F, and G do not present immediate concerns that require urgent follow-up compared to choices A, B, and C. Peripheral edema 2+ in bilateral lower extremities, soft uterine tone, large amount of lochia rubra, and a blood pressure of 136/86 mm Hg are important findings but do not necessitate immediate intervention or follow-up.