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The nurse is reviewing the chart of a client who gave birth 4 hours ago. Which factor increases the client's risk for postpartum hemorrhage?
- A. Labor and birth without pain medication
- B. Labor length of 8 hours
- C. Newborn weight of 9 lb 2 oz (4140 g)
- D. Third stage of labor lasting 20 minutes
Correct Answer: C
Rationale: A large newborn (macrosomia, >4000 g) increases the risk of uterine atony, a major cause of postpartum hemorrhage. Labor without pain medication, an 8-hour labor, and a 20-minute third stage are not significant risk factors.
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A practical nurse (PN) is assigned to care for a newborn with a neural tube defect. Which dressing, if applied by the PN, would need no further intervention by the charge nurse?
- A. Telfa dressing with antibiotic ointment
- B. Moist sterile nonadherent dressing
- C. Dry sterile dressing that is occlusive
- D. Sterile occlusive pressure dressing
Correct Answer: B
Rationale: Before surgical closure, the sac is prevented from drying by the application of a sterile, moist, nonadherent dressing over the defect. Dressings are changed frequently to keep them moist.
All of the following clients need attention. Which one should the nurse go to first?
- A. The nursing assistant reports that a client who had a T3 spinal cord transection several months ago has a severe headache and blurred vision.
- B. The nursing assistant needs help turning a client who had a CVA.
- C. The physician is about to examine a client who has multiple sclerosis and requests that the nurse be present.
- D. A client who has amyotrophic lateral sclerosis needs help with ambulating.
Correct Answer: A
Rationale: Severe headache and blurred vision in spinal cord injury suggest autonomic dysreflexia, a life-threatening emergency, prioritizing immediate attention over turning, examination, or ambulation.
The nurse is caring for a client with irritable bowel syndrome. Which of the following menu selections would be appropriate to offer the client?
- A. Beans, yogurt, and a mixed fruit cup
- B. Eggs, bagel, and a cup of black coffee
- C. Baked chicken, brown rice, and strawberries
- D. Roasted beef, broccoli, and a glass of iced tea
Correct Answer: C
Rationale: Baked chicken, brown rice, and strawberries are low-FODMAP, suitable for IBS. Beans, yogurt, coffee, and broccoli are high-FODMAP, likely to trigger symptoms.
The nurse is collecting data from a client with a history of alcohol use disorder who had an emergency appendectomy 3 days ago. Which of the following findings would indicate that the client is experiencing delirium tremens? Select all that apply.
- A. Bradypnea
- B. Diaphoresis
- C. Hallucinations
- D. Lethargy
- E. Tachycardia
Correct Answer: B,C,E
Rationale: Delirium tremens presents with diaphoresis, hallucinations, and tachycardia due to autonomic hyperactivity. Bradypnea and lethargy are not typical; agitation is more common.
The nurse is talking with the parent of a 1-day-old newborn who had a circumcision using the plastic ring method. Which of the following statements by the parent would require follow-up?
- A. I will contact the health care provider if bleeding does not stop with gentle pressure
- B. I should avoid using alcohol-based cleansing wipes during diaper changes
- C. I need to leave the device in place and allow it to fall off on its own
- D. I understand that yellow exudate on the area is a sign of infection
Correct Answer: D
Rationale: Yellow exudate is normal during circumcision healing, not a sign of infection, requiring further teaching. Contacting the provider for persistent bleeding, avoiding alcohol wipes, and leaving the device are correct.