Nokea
A nurse on a postpartum unit is receiving change-of-shift report for four clients. Which of the following.....
- A. A client who gave a birth 1 day ago and needs Rh˳(D) immune globulin.
- B. A client who gave a birth 3 days ago and reports breath fullness.
- C. A client who gave a birth 12 hr. ago and reports and increase in urinary output.
- D. A client who gave a birth 8 hr. ago and is saturating a perineal pad every hour.
Correct Answer: B
Rationale: The client who gave birth 3 days ago and reports breath fullness is showing signs of potential postpartum complications, such as a pulmonary embolism. Pulmonary embolism is a serious condition that can occur postpartum due to blood clot formation. Symptoms like breath fullness, chest pain, and shortness of breath should never be ignored in postpartum clients. This client requires immediate assessment and intervention to prevent further complications. The other options are concerning but do not indicate as urgent of a situation as breath fullness, which could be a life-threatening issue.
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A client in the first stage of labor reports severe lower back pain. What intervention is most effective?
- A. Administer an epidural block.
- B. Encourage frequent position changes.
- C. Apply a heating pad to the back.
- D. Perform a sterile vaginal exam.
Correct Answer: B
Rationale: Frequent position changes, especially to hands-and-knees or leaning forward, can relieve back pain caused by fetal position.
A nurse is caring for a client who is in labor and requests nonpharmacological pain management. Which of the following nursing actions promotes client comfort?
- A. Assisting the client into squatting position
- B. Having the client lie in a supine position
- C. Applying fundal pressure during contractions
- D. Encouraging the client to void every 6 hr.
Correct Answer: A
Rationale: Assisting the client into a squatting position can help relieve pain and discomfort during labor. Squatting can open up the pelvis, allowing the baby to descend and progress through the birth canal more effectively. This position can also help with gravity-assisted delivery, decreasing the pressure on the mother's back and helping to reduce labor pains. Encouraging various positions during labor can provide comfort and promote optimal positioning for delivery.
The nurse is assessing a client in labor with variable decelerations on the fetal monitor. What is the priority intervention?
- A. Increase oxytocin infusion.
- B. Reposition the client.
- C. Administer oxygen at 10 L/min.
- D. Notify the healthcare provider.
Correct Answer: B
Rationale: Repositioning the client can alleviate umbilical cord compression, the most common cause of variable decelerations.
A client, who is in the second trimester of pregnancy, gestation. The client is receiving magnesium sulfate tells the nurse that she has developed a reddish-pink intravenously for pre-eclampsia. Which assessment skin color on the palm of her hands. Which of the fol- requires immediate intervention?
- A. Blood pressure of 130/90 mm Hg
- B. Urine output of 20 mL in past hour
- C. Facial flushing
- D. Patellar reflexes 2+
Correct Answer: C
Rationale: Facial flushing in a pregnant client receiving magnesium sulfate for pre-eclampsia can be a sign of magnesium toxicity. Magnesium sulfate is a tocolytic agent used to prevent seizures in pre-eclamptic patients; however, excessive levels of magnesium can cause symptoms such as flushing, lethargy, blurred vision, slurred speech, and muscle weakness. In severe cases, magnesium toxicity can progress to respiratory depression, cardiac arrest, and death. Therefore, immediate intervention is required to prevent further complications. The other options do not present immediate concerning signs related to magnesium toxicity.
What technique is used for visualization and deepening in HypnoBirthing?
- A. counting contractions
- B. the on-off†switch
- C. visualizing the instruments used to assist with birth
- D. deepening into hypnosis to help push harder
Correct Answer: B
Rationale: The 'on-off' switch is a visualization technique used in HypnoBirthing to deepen relaxation.