Nokea
The nurse is monitoring a postpartum client with a boggy uterus. What is the priority intervention?
- A. Notify the healthcare provider.
- B. Massage the fundus until firm.
- C. Administer prescribed oxytocin.
- D. Check the client’s vital signs.
Correct Answer: B
Rationale: Massaging a boggy uterus stimulates contraction and reduces the risk of postpartum hemorrhage.
You may also like to solve these questions
What two steps of the CJMM are included in the assessment step of the nursing process?
- A. noticing cues and evaluating outcomes
- B. analyzing cues and generating solutions
- C. noticing and analyzing cues
- D. analyzing cues and taking action
Correct Answer: A
Rationale: In the assessment step of the nursing process, two steps of the CJMM (Clinical Judgment Model) that are included are noticing cues and evaluating outcomes. Noticing cues involves observing and recognizing relevant information or data related to the patient's health status, while evaluating outcomes involves assessing the effectiveness of the nursing interventions and patient responses to the care provided. By noticing cues, nurses gather information that guides their decision-making process, and by evaluating outcomes, they determine the impact of their actions on the patient's health and adjust the plan of care as needed. These two steps are essential in the assessment phase as they contribute to developing a comprehensive understanding of the patient's needs and progress towards achieving desired health outcomes.
The nurse is assessing a client diagnosed with placenta previa. Which findings should the nurse expect to note?
- A. Uterine rigidity.
- B. Severe abdominal pain.
- C. Bright red vaginal bleeding.
- D. Soft, relaxed, nontender uterus.
Correct Answer: C
Rationale: Placenta previa presents as painless bright red bleeding and a soft, non-tender uterus.
A nurse is caring for a client who is receiving oxytocin to augment labor. The client has an intrauterine pressure catheter and an internal fetal scalp electrode for monitoring. Which of the following is an indication that the nurse should discontinue the infusion?
- A. Contraction frequency every 3 min
- B. Contraction duration of 100 seconds
- C. Fetal heart rate with moderate
- D. variability Fetal heart rate of 118/min
Correct Answer: B
Rationale: Prolonged contractions lasting more than 90-120 seconds may reduce placental perfusion and oxygenation to the fetus, leading to fetal distress. This can result in fetal hypoxia and compromise. Therefore, if the contraction duration reaches 100 seconds, it is an indication for the nurse to discontinue the oxytocin infusion to prevent harm to the fetus. Monitoring for appropriate contraction duration is crucial to ensure the well-being of both the mother and the fetus during labor. While contraction frequency every 3 minutes, a fetal heart rate with moderate variability, and a fetal heart rate of 118/min can be normal findings during labor, a prolonged contraction duration is a concerning sign that requires immediate intervention.
A couple who has stated that they are LGBTQIA+ during prior visits arrives at the clinic for prenatal care. What can the nurse say in the waiting area to help them feel welcome and safe?
- A. You can take this tablet to an area in the waiting room and check in. Then bring the tablet back to me when you are done.
- B. Are you pregnant? Your paperwork says your name is Tom.
- C. You can have a seat, and a person from the LGBTQIA+ office will come to assist you.
- D. Here is our paperwork. It doesn't have a box for your sex, but you can write it next to the gender box.
Correct Answer: A
Rationale: Providing a neutral and respectful approach helps create a welcoming environment for LGBTQIA+ patients.
A parent asks the nurse what makes the opening between the baby's atrium close at birth? The nurse's response is that cardiovascular changes that cause to foramen ovale to close at birth are the direct result of:
- A. Increased pressure in the L atrium (with the increase in the blood flow to the L atrium from the lungs, the pressure is
- C. Increased pressure in the R atrium
- D. Changes in the hepatic blood flow
Correct Answer: C
Rationale: The foramen ovale is a normal fetal structure that allows blood to bypass the lungs by shunting blood from the right atrium to the left atrium. This is essential during fetal development since the lungs are not functioning until birth. After birth, when the baby takes its first breaths and the lungs start working, the pressure in the left atrium increases due to the increased blood flow from the pulmonary circulation. This increased pressure in the left atrium causes the foramen ovale to close, preventing blood from flowing from the right atrium to the left atrium. Therefore, the closure of the foramen ovale is a result of the increased pressure in the left atrium rather than any other cardiovascular changes.