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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 lochial flow. On inspection, the nurse finds that a perineal hematoma is beginning to form. Which assessment finding should the nurse obtain first?
- A. Hemoglobin and hematocrit
- B. Abdominal contour and bowel sounds
- C. Heart rate and blood pressure
- D. Urinary output and IV fluid intake
Correct Answer: C
Rationale: A perineal hematoma can cause significant pain and pressure, potentially leading to hemodynamic instability. Assessing heart rate and blood pressure first is crucial to detect signs of shock or circulatory compromise.
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The nurse is caring for a client whose fetus died in utero at 32-weeks gestation. After the fetus is delivered vaginally, the nurse implements routine fetal demise protocol and identification procedures Which action is most important for the nurse to take?
- A. Explain reasons consent for an infant autopsy is needed
- B. Determine if the mother desires a visit from her clergy
- C. Encourage the mother to hold and spend time with her baby
- D. Create a memory box of baby's footprints and photographs
Correct Answer: C
Rationale: Encouraging the mother to hold and spend time with her baby supports the grieving process, helping her acknowledge and create memories with her child.
The nurse is assessing a newborn who was precipitously delivered at 38-weeks gestation The newborn is tremulous, tachycardic, and hypertensive. Which assessment action is most important for the nurse to implement?
- A. Obtain a drug screen for cocaine
- B. Weigh and measure the newborn
- C. Determine reactivity of neonatal reflexes
- D. Perform gestational age assessment
Correct Answer: A
Rationale: Tremulousness, tachycardia, and hypertension in a newborn suggest possible drug exposure, such as cocaine, requiring an urgent drug screen to guide treatment.
A client at 40-weeks gestation is admitted in active labor, and laboratory findings indicate that she is HIV positive. Which actions should the nurse plan to perform? (Select all that apply.)
- A. Place client in a negative pressure room
- B. Implement droplet precautions
- C. Encourage the mother to bottle-feed
- D. Give antiviral medication intravenously
- E. Use standard precautions
Correct Answer: C,D,E
Rationale: HIV is transmitted through blood, body fluids, or breast milk, not air or droplets. Bottle-feeding (C) prevents transmission via breast milk, IV antiviral medication (D) reduces perinatal transmission, and standard precautions (E) are sufficient for infection control.
A client who is 32 weeks gestation comes to the women's health clinic and reports nausea and vomiting. On examination, the nurse notes that the client has an elevated blood pressure. Which action should the nurse implement next?
- A. Inspect the client's face for edema
- B. Ascertain the frequency of headaches
- C. Evaluate for history of cluster headaches
- D. Observe and time client's contractions
Correct Answer: A
Rationale: Elevated blood pressure at 32 weeks may suggest preeclampsia. Inspecting for facial edema is a priority to assess for fluid retention, a key sign of this condition.
A nurse is speaking with a client who is addicted to heroin and who just learned that she is pregnant. The client states, 'I just started taking methadone. Is there anything else I can do to make sure my baby is healthy?' Which information should the nurse provide?
- A. Describe genetic testing protocols
- B. Discontinue the methadone right away
- C. Sign up for group therapy sessions
- D. Start a prenatal care plan as soon as possible
Correct Answer: D
Rationale: Early prenatal care is critical for monitoring maternal and fetal health, managing opioid addiction with methadone under medical supervision, and addressing potential complications.