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The nurse is performing an assessment of a postpartum client. Which finding requires immediate action?
- A. Temperature of 100.4°F.
- B. Foul-smelling lochia.
- C. Fundus firm and midline.
- D. Breast tenderness on palpation.
Correct Answer: B
Rationale: Foul-smelling lochia may indicate an infection and requires prompt medical evaluation.
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A woman is experiencing mittelschmerz and increased vaginal discharge. Her temperature has increased by 0.6°C (1.0°F) over the past 36 hours. This most likely indicates what?
- A. Menstruation is about to begin.
- B. Ovulation will occur soon.
- C. Ovulation has occurred.
- D. She is pregnant, and will not menstruate.
Correct Answer: C
Rationale: Mittelschmerz, or mid-cycle pain, combined with a basal temperature rise and cervical mucus changes, is a sign that ovulation has occurred. These indicators are part of the body's natural fertility signals.
Which finding during a prenatal visit is most concerning in a client at 32 weeks gestation?
- A. Blood pressure of 120/80 mmHg
- B. Mild lower back pain
- C. Weight gain of 2 pounds in one week
- D. Proteinuria of +2 on a urine dipstick
Correct Answer: D
Rationale: Proteinuria is a potential sign of preeclampsia, requiring evaluation.
The nurse is educating a client about signs of preterm labor. What symptom should be reported immediately?
- A. Frequent urination.
- B. Low back pain and cramping.
- C. Increased appetite.
- D. Braxton Hicks contractions.
Correct Answer: B
Rationale: Low back pain and cramping can indicate preterm labor and should be reported immediately for further evaluation.
A client in labor is receiving an epidural for pain relief. What is the nurse's priority assessment immediately after the procedure?
- A. Monitor maternal blood pressure.
- B. Assess fetal heart rate.
- C. Check for bladder distention.
- D. Evaluate the client's pain level.
Correct Answer: A
Rationale: Monitoring maternal blood pressure is essential to detect and manage hypotension, a common side effect of epidurals.
A client at 12 weeks' gestation asks about managing constipation during pregnancy. What is the nurse's best advice?
- A. Take a laxative daily.
- B. Increase fiber intake and fluids.
- C. Avoid physical activity.
- D. Limit vegetable consumption.
Correct Answer: B
Rationale: Increasing dietary fiber and fluids helps relieve constipation, which is common during pregnancy.