Nokea
The nurse is caring for a multiparous client 48 hours after cesarean delivery. Which finding indicates a potential complication?
- A. Clear urine output via catheter.
- B. Incisional pain relieved by medication.
- C. Scant lochia serosa.
- D. Homan's sign negative bilaterally.
Correct Answer: C
Rationale: Scant lochia serosa at 48 hours may indicate retained clots or infection, requiring further assessment.
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A multigravid client is in active labor with twins at 38 weeks' gestation. The nurse should monitor the client closely for symptoms of which of the following?
- A. Pregnancy-induced hypertension.
- B. Urinary tract infection.
- C. Chorioamnionitis.
- D. Precipitous delivery.
Correct Answer: D
Rationale: Twin pregnancies increase the risk of precipitous delivery due to uterine overdistension, which can lead to rapid labor. Hypertension, infections, or chorioamnionitis are possible but less specific to twins.
A mother is visiting her neonate in the neonatal intensive care unit. Her baby is fussy and the mother wants to know what to do. In order to quiet a sick neonate, which of the following can the nurse teach the mother to do?
- A. Bring in toys for distraction.
- B. Place a musical mobile over the crib.
- C. Stroke the neonate's back.
- D. Use constant, gentle touch.
Correct Answer: D
Rationale: Constant, gentle touch is soothing and minimizes overstimulation for a sick neonate.
A woman who is Rh-negative has delivered an Rh-positive infant. The nurse explains to the client that she will receive RhoGAM. The nurse determines that the client understands the purpose of RhoGAM when she states:
- A. "RhoGAM will protect my next baby if it is Rh-negative."
- B. "RhoGAM will prevent antibody formation in my blood."
- C. "RhoGAM will be given to prevent German measles."
- D. "RhoGAM will be used to prevent bleeding in my newborn."
Correct Answer: B
Rationale: RhoGAM prevents maternal antibody formation against Rh-positive blood.
While assessing the fundus of a multiparous client 36 hours after delivery of a term neonate, the nurse notes a separation of the abdominal muscles. The nurse should tell the client:
- A. She will have a surgical repair at 6 weeks postpartum.
- B. To remain on bed rest until resolution occurs.
- C. The separation will resolve on its own with the right posture and diet.
- D. To perform exercises involving head and shoulder raising in a lying position.
Correct Answer: D
Rationale: Diastasis recti often resolves with specific exercises like head and shoulder raises, which strengthen abdominal muscles.
After instructing a multigravid client at 10 weeks' gestation diagnosed with chronic hypertension about the need for frequent prenatal visits, the nurse determines that the instructions have been successful when the client states which of the following?
- A. "I may develop hyperthyroidism because of my high blood pressure."
- B. "I need close monitoring because I may have a small-for-gestational-age infant."
- C. "It's possible that I will have excess amniotic fluid and may need a cesarean section."
- D. "I may develop placenta accreta, so I need to keep my clinic appointments."
Correct Answer: B
Rationale: Chronic hypertension increases the risk of having a small-for-gestational-age infant.