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The nurse is monitoring a postpartum client. What finding requires immediate action?
- A. Fundus firm and midline.
- B. Lochia rubra with large clots.
- C. Mild perineal discomfort.
- D. Slight swelling of the feet.
Correct Answer: B
Rationale: The correct answer is B because Lochia rubra with large clots may indicate excessive bleeding or a possible postpartum hemorrhage, which requires immediate intervention to prevent complications. A: Fundus firm and midline is a normal finding postpartum. C: Mild perineal discomfort is expected after childbirth. D: Slight swelling of the feet is common due to fluid shifts and does not require immediate action.
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A nurse is reviewing a laboratory results for a client who is at 33 weeks of gestation and has preeclampsia. Which of the following laboratory results should the nurse report to the provider?
- A. BUN 35 mg/dL
- B. Hgb 15 mg/dL
- C. Bilirubin 0.6 mg/dL
- D. Hct 37%
Correct Answer: A
Rationale: The correct answer is A: BUN 35 mg/dL. In preeclampsia, elevated BUN levels indicate impaired kidney function, a serious complication. High BUN can lead to renal damage. Hgb, Hct, and Bilirubin levels are within normal ranges for pregnancy, so they do not indicate a critical issue. Reporting BUN level is crucial for monitoring kidney function and preventing further complications in preeclampsia.
Immediately after the forceps assists in the birth of an infant, what should the nurse do with the baby?
- A. Assess infant for signs of trauma
- B. Administer a vitamin K injection
- C. Provide immediate breastfeeding
- D. Monitor for signs of hypoglycemia
Correct Answer: A
Rationale: Rationale: Immediately after forceps-assisted birth, assessing the infant for signs of trauma is crucial for detecting any injuries or complications. This ensures prompt intervention if needed. Administering a vitamin K injection, providing immediate breastfeeding, and monitoring for hypoglycemia are important but secondary tasks that can be done after ensuring the infant's safety.
After being in labor several hours with no progress the patient diagnosed with CPD and must have a c/s. the patient is worried that she will not be able to have any future children vaginally. After sharing this info with her care provider, the nurse would anticipate should would receive what type of incision?
- A. Transverse
- B. Vertical
- C. Low vertical
- D. Pfannenstiel
Correct Answer: B
Rationale: The correct answer is B: Vertical incision. In cases of CPD (cephalopelvic disproportion) where labor is not progressing and a cesarean section is necessary, a vertical incision is typically performed. This type of incision allows for better access to the uterus and is preferred in emergency situations like CPD. A transverse incision (choice A) is commonly used in elective c-sections but may not provide enough access in cases of CPD. Low vertical (choice C) is not ideal for CPD as it limits visibility and access. Pfannenstiel incision (choice D) is a horizontal incision placed low on the abdomen and is typically used in elective c-sections, not specifically for CPD cases.
The primigravida is admitted to the birthing and labor unit, but
- A. The initial response from the nurse will be to:
- B. Take health history
- C. Perform vaginal exam
- D. Review prenatal record
Correct Answer: B
Rationale: The correct answer is B: Take health history. This is the initial response because obtaining the patient's health history provides crucial information about the primigravida's medical background, current health status, any complications, and helps in assessing the risk factors for labor and delivery. This information guides the nurse in providing appropriate care and making informed decisions during the labor process.
Choice A (The initial response from the nurse will be to) is vague and not specific enough to address the immediate needs of the patient.
Choice C (Perform vaginal exam) is not appropriate as the first action because it can be invasive and should only be performed after obtaining the health history to determine the necessity and timing of the exam.
Choice D (Review prenatal record) is important but should come after taking the health history to supplement the information obtained and provide a comprehensive understanding of the patient's pregnancy course.
The nurse is caring for a postpartum client who reports feeling overwhelmed and tearful. What is the nurse's priority intervention?
- A. Administer a sedative as prescribed.
- B. Encourage the client to rest and sleep.
- C. Provide emotional support and reassurance.
- D. Refer the client to a mental health professional.
Correct Answer: C
Rationale: The correct answer is C: Provide emotional support and reassurance. This is the priority intervention because the client is feeling overwhelmed and tearful, indicating a need for immediate emotional support. Administering a sedative (A) may mask the underlying issue and is not addressing the client's emotional needs. Encouraging rest and sleep (B) is important but secondary to addressing the client's emotional state. Referring the client to a mental health professional (D) may be necessary in the long term but is not the immediate priority in this situation. Emotional support and reassurance can help the client feel validated and supported in the moment.