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The nurse is caring for a postpartum client with excessive bleeding. What is the priority nursing intervention?
- A. Administer IV fluids.
- B. Massage the uterine fundus.
- C. Notify the healthcare provider.
- D. Check the client's vital signs.
Correct Answer: B
Rationale: The correct answer is B: Massage the uterine fundus. This is the priority intervention because excessive bleeding postpartum may indicate uterine atony, which can lead to hemorrhage. Massaging the uterine fundus helps to stimulate uterine contractions and control bleeding. Administering IV fluids (A) can be important, but controlling bleeding takes precedence. Notifying the healthcare provider (C) can be done after implementing immediate interventions. Checking vital signs (D) is important, but addressing the underlying cause of bleeding is the priority.
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A woman in labor reports a gush of fluid from her vagina. What is the nurse's first action?
- A. Check the fetal heart rate
- B. Assess the fluid for meconium staining
- C. Perform a sterile vaginal examination
- D. Notify the healthcare provider
Correct Answer: A
Rationale: The correct answer is A: Check the fetal heart rate. This is the first action to assess the well-being of the fetus after the reported fluid gush, ensuring fetal safety. Checking fetal heart rate is crucial in determining fetal distress. Assessing for meconium staining (B) is important but comes after confirming fetal well-being. Performing a sterile vaginal examination (C) may introduce infection and should be avoided without proper indications. Notifying the healthcare provider (D) is necessary but should follow initial assessment of fetal status.
The nurse assures the breastfeeding mother that she will know that her infant is getting an adequate supply of breast milk if the infant gains weight and:
- A. Rarely sucks on a pacifier.
- B. Ha several hard stools daily
- C. Voids 6 or more times a day
- D. Awakens to feed every 4 hours
Correct Answer: C
Rationale: The correct answer is C: Voids 6 or more times a day. Adequate breast milk intake is indicated by frequent urination (6 or more times/day) in infants. This shows the infant is hydrated and receiving enough milk. The other choices are incorrect because A) pacifier use doesn't indicate milk supply, B) hard stools can be a sign of dehydration or other issues, and D) feeding every 4 hours is a general guideline but not a definitive indicator of milk supply.
How can a nurse reduce the risk of infection in a newborn in the NICU?
- A. Maintain strict hand hygiene
- B. Limit visitors and monitor closely for signs of infection
- C. Ensure proper sterilization of equipment
- D. Administer prophylactic antibiotics
Correct Answer: B
Rationale: Rationale for Correct Answer (B): Limiting visitors and monitoring closely for signs of infection in a newborn in the NICU is crucial because newborns are highly vulnerable to infections. By restricting visitors, the risk of introducing pathogens is reduced. Close monitoring allows for early detection of any signs of infection, enabling prompt intervention to prevent complications.
Summary of Other Choices:
A: While maintaining strict hand hygiene is important, it alone is not sufficient to reduce the risk of infection in a newborn in the NICU.
C: Proper sterilization of equipment is essential but may not directly address the risk of infection transmission from visitors or other sources.
D: Administering prophylactic antibiotics is not recommended as a routine measure due to the potential for antibiotic resistance and adverse effects in newborns. Monitoring and prevention are preferred over indiscriminate antibiotic use.
The nurse is assessing a postpartum client. Which finding requires immediate intervention?
- A. Fundus firm and midline.
- B. Lochia rubra with large clots.
- C. Mild swelling in the perineal area.
- D. Breast tenderness on day 2 postpartum.
Correct Answer: B
Rationale: The correct answer is B because Lochia rubra with large clots could indicate excessive bleeding, which is a postpartum hemorrhage and requires immediate intervention to prevent further complications. A: Fundus firm and midline is a normal finding. C: Mild swelling in the perineal area is expected after childbirth. D: Breast tenderness on day 2 postpartum is a common finding due to milk production starting.
Which nursing intervention can help prevent postpartum depression?
- A. Provide printed educational material
- B. Encourage the mother to join a support group
- C. Assess the mother for risk factors of depression
- D. Administer antidepressants as prescribed
Correct Answer: B
Rationale: The correct answer is B because joining a support group can provide emotional support and reduce feelings of isolation, which are key factors in preventing postpartum depression. Printed educational material (A) may not offer personalized support. Assessing for risk factors (C) is important but alone may not prevent depression. Administering antidepressants (D) is a treatment, not a prevention strategy.