Nokea
Which data in the patient's history should the nurse recognize as being pertinent to a possible diagnosis of postpartum depression?
- A. Previous depressive episode
- B. Unexpected operative birth
- C. Ambivalence during the first trimester
- D. Second pregnancy in a 3-year period
Correct Answer: A
Rationale: A previous history of depression is a significant risk factor for postpartum depression. Women who have experienced a depressive episode in the past are more likely to develop postpartum depression compared to those without such a history. Recognizing this pertinent data in the patient's history can help the nurse identify individuals at higher risk for postpartum depression and provide appropriate support and intervention. The other options mentioned (B. Unexpected operative birth, C. Ambivalence during the first trimester, D. Second pregnancy in a 3-year period) may also contribute to emotional distress but are not as directly linked to postpartum depression as a previous depressive episode.
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A healthcare professional is reviewing the laboratory values of a client who has respiratory acidosis. Which of the following findings should the healthcare professional expect?
- A. HCO3- 30 mEq/L
- B. PaCO2 50 mm Hg
- C. pH 7.45
- D. Potassium 3.3 mEq/L
Correct Answer: B
Rationale: In respiratory acidosis, the primary disturbance is an increase in PaCO2 levels above the normal range of 35-45 mm Hg. Option B, PaCO2 50 mm Hg, indicates an elevated partial pressure of carbon dioxide, which is consistent with respiratory acidosis. Options A, C, and D are not directly indicative of respiratory acidosis. HCO3- (Option A) is more related to metabolic acidosis or alkalosis, pH (Option C) is within the normal range indicating no acid-base imbalance, and potassium (Option D) levels are not specific to respiratory acidosis.
A client with acute respiratory failure (ARF) may present with which of the following manifestations? (Select one that doesn't apply.)
- A. Severe dyspnea
- B. Decreased level of consciousness
- C. Headache
- D. Nausea
Correct Answer: D
Rationale: In acute respiratory failure (ARF), the body is not getting enough oxygen, leading to respiratory distress. Symptoms of ARF typically include severe dyspnea (difficulty breathing), decreased level of consciousness due to hypoxia, and headache from inadequate oxygenation to the brain. Nausea is not a typical manifestation of ARF and would not be expected in this condition.
A woman delivered a baby 9lbs 10oz 1 hour ago. When you
arrive to perform a 15-minute assessment she tells you that she feels
all wet underneath. You discover that both pads are completely
saturated and that she’s lying in a 6-inch diameter of blood. What
does nurse do first
- A. Assess the fundus for firmness
- B. Change the patient's pads
- C. Notify the provider
- D. Document the findings
Correct Answer: A
Rationale: In this scenario, the priority action for the nurse to take is to assess the source of the woman's feeling of wetness underneath her. This could indicate a significant amount of postpartum bleeding, also known as hemorrhage. It is crucial to determine if she is experiencing excessive bleeding as this can be life-threatening if not addressed promptly. By identifying the source of the wetness, the nurse can assess the situation and take appropriate actions to address any potential complications. Once the severity of bleeding is determined, further assessments and interventions can be initiated accordingly.
A nurse is caring for a client who is 1 day postpartum and is taking a sitz bath. To determine the client's tolerance of the procedure, which of the following assessments should the nurse perform?
- A. Bladder distention
- B. Pulse rate
- C. Respiratory rate
- D. Color of lochia
Correct Answer: B
Rationale: The nurse should assess the client's pulse rate to determine the client's tolerance of the sitz bath. An elevated pulse may indicate that the sitz bath is causing discomfort or stress to the client. Monitoring the pulse rate is essential to ensure the client's safety and comfort during the procedure. Bladder distention, respiratory rate, and color of lochia are important assessments in postpartum care but are not specifically related to determining the client's tolerance of a sitz bath.
The nurse is teaching a client about signs of postpartum hemorrhage. What statement indicates understanding?
- A. Passing a few clots is normal.
- B. Soaking one pad in an hour is concerning.
- C. Heavy bleeding stops within 48 hours.
- D. I should ignore mild cramping.
Correct Answer: B
Rationale: Soaking a pad in an hour may indicate postpartum hemorrhage and should be reported immediately.