Nokea
The nurse is caring for a client who had a cesarean section under spinal anesthesia less than 2 hours ago. Which of the following nursing actions is appropriate at this time?
- A. Elevate the head of the bed 60 degrees.
- B. Report absence of bowel sounds to the physician.
- C. Have her turn and deep breathe every 2 hours.
- D. Assess for patellar hyperreflexia bilaterally.
Correct Answer: C
Rationale: Post-spinal anesthesia, it is important to encourage the patient to change positions to prevent complications such as atelectasis and improve circulation.
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What is a risk factor for uterine atony?
- A. small for gestational age
- B. primipara
- C. multiple gestation
- D. intrauterine growth restriction
Correct Answer: C
Rationale: Risk factors for uterine atony include multiple gestation and large infants.
The nurse must initiate discharge teaching with the couple regarding the need for an infant car seat for the day of discharge. Which of the following responses indicates that the nurse acted appropriately? The nurse discussed the need with the couple:
- A. On admission to the labor room.
- B. In the client room after the delivery.
- C. When the client put the baby to the breast for the first time.
- D. The day before the client and baby are to leave the hospital.
Correct Answer: D
Rationale: Teaching about the need for an infant car seat should occur before discharge to ensure the parents have time to arrange for one, typically the day before discharge.
A patient who has been on prolonged bedrest for bleeding associated with placenta previa was taken to the operating room for an emergency cesarean delivery. Sixteen hours postoperatively, the patient complains that her left leg is hurting. The nurse finds that the entire left leg is swollen and has pitting edema, while the right leg appears to be normal. Which order does the nurse anticipate when paging the health care provider to the room?
- A. White blood cell count (WBC)
- B. Ultrasound of the leg
- C. X-ray of the leg
- D. Serum creatinine
Correct Answer: B
Rationale: The correct answer is B: Ultrasound of the leg. In this scenario, the patient is at risk for deep vein thrombosis (DVT) due to prolonged bedrest and recent surgery. The symptoms of leg pain, swelling, and pitting edema raise suspicion for DVT. An ultrasound of the leg is the most appropriate diagnostic test to confirm the presence of a blood clot. This test is non-invasive, highly sensitive, and specific for detecting DVT. It allows for prompt diagnosis and initiation of appropriate treatment such as anticoagulation therapy to prevent potential complications like pulmonary embolism.
Summary:
- A: White blood cell count (WBC) is not indicated for evaluating leg pain and swelling in this context.
- C: X-ray of the leg is not useful for diagnosing DVT, as it primarily shows bones and is not sensitive for detecting blood clots.
- D: Serum creatinine is a test for kidney function and is not relevant for assessing
Which client is at greatest risk for early PPH?
- A. Primiparous woman (G 2, P 1-0-0-1) being prepared for an emergency cesarean birth for fetal distress
- B. Woman with severe preeclampsia on magnesium sulfate whose labor is being
- C. Multiparous woman (G 3, P 2-0-0-2) with an 8-hour labor
- D. Primigravida in spontaneous labor with preterm twins
Correct Answer: B
Rationale: The correct answer is B because a woman with severe preeclampsia on magnesium sulfate is at the greatest risk for early postpartum hemorrhage (PPH) due to the increased risk of placental abruption, coagulopathy, and uterine atony associated with preeclampsia and magnesium sulfate use. Preeclampsia can lead to poor placental perfusion, increasing the risk of hemorrhage during and after delivery. Magnesium sulfate can also affect blood clotting mechanisms, further increasing the risk of excessive bleeding. The other choices are less likely to be at greatest risk for early PPH. Choice A involves a primiparous woman with cesarean delivery, which may have controlled bleeding. Choice C is a multiparous woman with a relatively short labor duration, which is not a significant risk factor for early PPH. Choice D is a primigravida with preterm twins, which does not inherently increase the risk of early PPH
What nursing intervention does the nurse include in the plan of care for a person with mastitis?
- A. Provide antipyretic.
- B. Stop antibiotics when redness is resolved.
- C. Encourage the person to stop breast-feeding.
- D. Start an IV and prepare for signs of sepsis.
Correct Answer: A
Rationale: Antipyretics help manage the fever associated with mastitis along with antibiotic therapy to treat the infection.