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The nurse is teaching a client about postpartum care. Which statement indicates a need for further teaching?
- A. I will avoid heavy lifting for 6 weeks.
- B. It’s normal to have heavy bleeding for 4 weeks.
- C. I will call my doctor if I develop a fever.
- D. I should continue taking my prenatal vitamins.
Correct Answer: B
Rationale: The correct answer is B because heavy bleeding for 4 weeks postpartum is abnormal and could indicate a complication. The client should seek medical attention if experiencing heavy bleeding beyond the normal range. Choices A, C, and D are all correct statements for postpartum care. A - avoiding heavy lifting helps prevent strain on healing tissues, C - fever could indicate infection, and D - continuing prenatal vitamins supports postpartum recovery.
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The nurse is assessing a client in the third trimester with suspected placental abruption. What finding supports this diagnosis?
- A. Painless bright red bleeding.
- B. Boardlike abdomen and severe pain.
- C. Soft, relaxed uterus.
- D. Increased fetal movement.
Correct Answer: B
Rationale: The correct answer is B: Boardlike abdomen and severe pain. This finding supports the diagnosis of placental abruption because it indicates a significant and sudden separation of the placenta from the uterine wall, leading to intense pain and rigidity of the abdomen due to internal bleeding. Painless bright red bleeding (choice A) is more indicative of placenta previa, not placental abruption. A soft, relaxed uterus (choice C) is not typical in placental abruption, which usually presents with uterine tenderness and rigidity. Increased fetal movement (choice D) is not specific to placental abruption and can occur in various pregnancy conditions.
A nurse is performing a vaginal exam on a client who is in active labor. The nurse notes the umbilical cord protruding through the cervix. Which of the following actions should the nurse take?
- A. Administer oxytocin to the client via intravenous infusion.
- B. Apply oxygen at 2 L/min via nasal cannula.
- C. Prepare for insertion of an intrauterine pressure catheter.
- D. Assist the client into the knee-chest position.
Correct Answer: D
Rationale: The correct answer is D: Assist the client into the knee-chest position. This position helps relieve pressure on the umbilical cord, preventing compression and potential harm to the fetus. By positioning the client in knee-chest, gravity can aid in moving the fetus off the cord. Administering oxytocin (choice A) is not appropriate as the priority is to relieve pressure on the cord. Applying oxygen (choice B) does not address the immediate risk posed by the cord prolapse. Insertion of an intrauterine pressure catheter (choice C) is not indicated when the priority is to alleviate cord compression.
A nurse is caring for a patient who discloses they are experiencing family violence. What nursing action should the nurse take to support the patient and promote their safety?
- A. Provide a safe environment for the patient to further disclose their experience.
- B. Converse with the patient’s partner and ask why IPV is occurring in their home.
- C. Report the patient’s accusations to other members of the family.
- D. Propose a plan to leave the abuser today.
Correct Answer: A
Rationale: The correct answer is A: Provide a safe environment for the patient to further disclose their experience. This is the most appropriate action as it prioritizes the patient's safety and well-being. By creating a safe space, the nurse can encourage the patient to share more details about the violence they are experiencing. This can help the nurse assess the situation accurately and provide necessary support and resources.
Choices B, C, and D are incorrect:
B: Conversing with the patient's partner and asking why IPV is occurring is inappropriate as it may put the patient at further risk and breach confidentiality.
C: Reporting the patient's accusations to other family members could worsen the situation and further endanger the patient.
D: Proposing a plan to leave the abuser today may not be feasible or safe without proper assessment and planning.
A nurse is preparing to administer magnesium sulfate IV to a client who is experiencing preterm labor. Which of the following is the priority nursing assessment for this client?
- A. Temperature
- B. Fetal heart rate (FHR)
- C. Bowel sounds
- D. Respiratory rate
Correct Answer: B
Rationale: The correct answer is B: Fetal heart rate (FHR). When administering magnesium sulfate for preterm labor, monitoring the fetal heart rate is crucial as magnesium sulfate can affect the fetal heart rate. It is important to assess for any signs of fetal distress promptly.
A: Temperature is important to monitor for signs of magnesium toxicity, but not the priority assessment in this situation.
C: Bowel sounds are not directly related to the administration of magnesium sulfate for preterm labor.
D: Respiratory rate is important to monitor for respiratory depression from magnesium sulfate, but assessing the fetal heart rate takes precedence in this scenario.
A client at 37 weeks' gestation reports sudden gush of clear fluid. What is the nurse's priority action?
- A. Assess for fetal heart rate changes.
- B. Check maternal vital signs.
- C. Perform a sterile vaginal examination.
- D. Notify the healthcare provider.
Correct Answer: A
Rationale: The correct answer is A: Assess for fetal heart rate changes. This is the priority action because the sudden gush of clear fluid may indicate rupture of membranes, potentially leading to fetal distress. Assessing fetal heart rate changes helps determine the urgency of the situation and guides further interventions. Checking maternal vital signs (B) is important but not the priority in this scenario. Performing a sterile vaginal examination (C) should only be done after confirming rupture of membranes to prevent infection. Notifying the healthcare provider (D) can be done after assessing fetal well-being.