Nokea
The nurse is caring for a postpartum client who is complaining of severe pain and a feeling of pressure in her perineum. Her fundus is firm, and she has a moderate lochia flow. On inspection the nurse finds that a perineal hematoma is beginning to form. Which assessment findings show the nurse obtain first?
- A. Abdominal contour and bowel sounds
- B. Hemoglobin and hematocrit
- C. Heart rate and blood pressure
- D. Urinary output and IV fluid intake
Correct Answer: C
Rationale: Hematomas can cause significant blood loss, so assessing heart rate and blood pressure (C) is critical.
You may also like to solve these questions
For the pregnant patient who is a vegan, what combination of foods will the nurse advise to meet the nutritional needs for all essential amino acids?
- A. Eggs and beans
- B. Fruits and vegetables
- C. Grains and legumes
- D. Vitamin and mineral supplements
Correct Answer: C
Rationale: The correct answer is C (Grains and legumes) because when combined, they provide all essential amino acids needed for a vegan pregnant patient. Grains are low in lysine but high in methionine, while legumes are high in lysine but low in methionine. By consuming both, the patient can achieve a complete protein profile. Choice A (Eggs and beans) is incorrect as vegans do not consume eggs. Choice B (Fruits and vegetables) lacks adequate protein and essential amino acids. Choice D (Vitamin and mineral supplements) is important for overall health but does not provide the necessary amino acids.
A client at 41-weeks gestation is admitted to the labor and delivery unit for induction of labor. The client's cervix is dilated 2 cm, 50% effaced, and the fetus is at -2 station. The Bishop score is 4. What action should the nurse anticipate?
- A. Administration of prostaglandin gel.
- B. Rupture of membranes.
- C. Administration of oxytocin.
- D. Preparation for a cesarean section.
Correct Answer: A
Rationale: A Bishop score of 4 indicates an unfavorable cervix, and prostaglandin gel is typically used to ripen the cervix before induction.
The RN is delegating tasks to the unlicensed assistive personnel (UAP). Which tasks can the nurse delegate?
- A. Teaching the patient about breast care
- B. Assessment of a patient's lochia and perineal area
- C. Assisting a patient to the bathroom for the first time after birth
- D. Vital signs on a postpartum patient who delivered the night before
Correct Answer: D
Rationale: Nurses can delegate stable, routine tasks like taking vital signs or assisting with noncritical activities but cannot delegate assessments or teaching.
The nurse is teaching a woman how to use her basal body temperature (BBT) pattern as a tool to assist her in conceiving a child. Which temperature pattern indicates the occurrence of ovulation, and therefore, the best time for intercourse to ensure conception?
- A. Between the time the temperature falls and rises
- B. Between 36 and 48 hours after the temperature rises
- C. When the temperature falls and remains low for 36 hours
- D. Within 72 hours before the temperature falls
Correct Answer: A
Rationale: In most women, the BBT drops slightly 24 to 36 hours before ovulation and rises 24 to 72 hours after ovulation, when the corpus luteum of the ruptured ovary produces progesterone. Therefore, intercourse between the time of the temperature fall and rise (A) is the best time for conception.
A pregnant patient asks the nurse if she can double her prenatal vitamin dose because she does not like to eat vegetables. What is the nurse's response regarding the danger of taking excessive vitamins?
- A. Increases caloric intake
- B. Has toxic effects on the fetus
- C. Increases absorption of all vitamins
- D. Promotes development of pregnancy-induced hypertension (PIH)
Correct Answer: B
Rationale: The correct answer is B: Has toxic effects on the fetus. Doubling prenatal vitamin dose can lead to excessive intake of certain vitamins like Vitamin A, which can be harmful to the fetus. Excessive vitamins can cause toxicity and harm the developing baby. Other choices are incorrect: A is irrelevant, C is misleading, and D is not related to excessive vitamin intake.