Nokea
The nurse is caring for a postpartum woman and her 2-hour-old baby. The new mother has been preoccupied with breastfeeding and visitors, but suddenly she complains of dizziness and is light-headed. Which response by the nurse is appropriate?
- A. Explain that she needs to drink more fluids and eat because she needs to replace fluids and calories.
- B. Encourage the patient to rest, and ask a family member to watch the newborn in the crib.
- C. Tell the patient that the dizziness is probably caused by her pain medication and that it is normal.
- D. Obtain vital signs, assess fundal tone, and observe for excessive lochia.
Correct Answer: D
Rationale: Obtaining vital signs, assessing fundal tone, and observing for excessive lochia is appropriate to identify the cause of dizziness.
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A client has just been transferred to the postpartum unit from labor and delivery. Which of the following tasks should the registered nurse delegate to the nursing care assistant?
- A. Assess client 's fundal height.
- B. Teach client how to massage her fundus.
- C. Take the client 's vital signs.
- D. Document quantity of lochia in the chart.
Correct Answer: C
Rationale: The nursing care assistant can take vital signs, while the registered nurse is responsible for more complex assessments like fundal height and teaching skills such as massaging the fundus.
The nurse is assessing the laboratory report on a 2-day postpartum G1 P1001. The woman had a normal postpartum assessment this morning. Which of the following results should the nurse report to the primary health care provider?
- A. White blood cells, 12,500 cells/mm3.
- B. Red blood cells, 4,500,000 cells/mm3.
- C. Hematocrit, 26%.
- D. Hemoglobin, 11 g/dL
Correct Answer: C
Rationale: A hematocrit of 26% indicates possible anemia, and it should be reported to the healthcare provider for further evaluation.
The nurse should warn a client who is about to receive Methergine (ergonovine) of which of the following side effects?
- A. Headache.
- B. Nausea.
- C. Cramping.
- D. Fatigue.
Correct Answer: A
Rationale: Methergine is used to prevent postpartum hemorrhage, but it can cause side effects such as headache, nausea, and cramping. The nurse should inform the client about these possible side effects to promote informed decision-making.
A client is receiving an epidural infusion of a narcotic for pain relief after a cesarean section. The nurse would report to the anesthesiologist if which of the following were assessed?
- A. Respiratory rate 8 rpm.
- B. Complaint of thirst.
- C. Urinary output of 250 mL/hr.
- D. Numbness of feet and ankles.
Correct Answer: A
Rationale: A respiratory rate of 8 breaths per minute indicates respiratory depression, which must be reported immediately as a potential complication of narcotic use.
What nursing diagnosis would be appropriate for the person with a coagulation disorder?
- A. risk for bleeding
- B. risk for fluid overload
- C. risk for breast-feeding failure
- D. risk for hypertension
Correct Answer: B
Rationale: The correct answer is B: risk for fluid overload. A person with a coagulation disorder is at risk for excessive bleeding, which may lead to fluid overload due to blood loss and subsequent fluid replacement. This nursing diagnosis addresses the potential complications related to fluid imbalance in this population.
Incorrect choices:
A: risk for bleeding - While bleeding is a concern for someone with a coagulation disorder, this choice does not address the potential fluid overload that may result from excessive bleeding.
C: risk for breast-feeding failure - This choice is not relevant to the immediate health concerns of a person with a coagulation disorder.
D: risk for hypertension - Hypertension is not directly related to a coagulation disorder, therefore this choice is not appropriate as a nursing diagnosis in this context.