Nokea
The nurse's initial response if a pulmonary embolism is suspected should be to:
- A. Start a second intravenous (IV) line and prepare for transfusion.
- B. Raise the head of the bed and administer oxygen.
- C. Insert a catheter to monitor urine output.
- D. Lower the head of the bed and elevate the legs.
Correct Answer: B
Rationale: In cases of pulmonary embolism oxygen should be administered to support breathing and help oxygenate the blood. oxygen should be administered to support breathing and help oxygenate the blood.
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The nurse is caring for a client who had an emergency cesarean section, with her husband in attendance, the day before. The baby 's Apgar was 9/9. The woman and her partner had attended childbirth education classes and had anticipated having a water birth with family present. Which of the following comments by the nurse is appropriate?
- A. Sometimes babies just don 't deliver the way we expect them to.
- B. With all of your preparations, it must have been disappointing for you to have had a cesarean.
- C. I know you had to have surgery, but you are very lucky that your baby was born healthy.
- D. At least your husband was able to be with you when the baby was born.
Correct Answer: B
Rationale: The nurse should acknowledge the emotional impact of an unplanned cesarean section while validating the mother's feelings.
What assessment finding would indicate a fluid volume deficit?
- A. skin tenting with testing of skin turgor
- B. hypertension
- C. bradycardia
- D. bounding pulse
Correct Answer: A
Rationale: Skin tenting indicates dehydration, a sign of fluid volume deficit.
The nurse is assessing a patient who is 12 hours postpartum. The uterus is firm to palpation, at midline, and is 1 cm below the umbilicus with continuous heavy vaginal bleeding. What is the nurse’s first action?
- A. Massage the uterus and resume the IV Pitocin drip.
- B. Change the peri-pad and reassess the bleeding.
- C. Call the provider to check for a cervical laceration.
- D. Administer the ordered iron supplement and ibuprofen.
Correct Answer: A
Rationale: The nurse must address the uterine tone and bleeding immediately by massaging the uterus and resuming Pitocin to prevent hemorrhage.
A woman is 1 hour postcesarean delivery with nausea and an estimated blood loss of 1,200 mL. She is currently experiencing heavy vaginal bleeding and has a uterus that firms with massage. She has a history of asthma with a current O2 saturation of 89%. The licensed provider has ordered Cytotec 800 mcg and Methergine 0.2 mg. What collaborative communication should occur between the nurse and provider?
- A. Since the total blood loss is under 1,500 mL, Cytotec and Methergine administration could be delayed for a time.
- B. Cytotec should be given rectally because the patient is already nauseated, and the Methergine route should be ordered.
- C. Recommend that the abdominal dressing be removed to inspect for incisional bleeding.
- D. Recommend that the patient not get Methergine because she has a history of asthma.
Correct Answer: D
Rationale: Given the patient’s asthma, Methergine should not be administered and alternative treatments should be discussed.
Which classification of placental separation is not recognized as an abnormal adherence pattern?
- A. Placenta accreta
- B. Placenta increta
- C. Placenta percreta
- D. Placenta abruptio
Correct Answer: D
Rationale: Placenta abruptio, also known as abruptio placentae, is the premature separation of the placenta from the uterine wall before delivery. It is not classified as an abnormal adherence pattern like placenta accreta, increta, and percreta. Placenta accreta occurs when the placenta attaches too deeply into the uterine wall. Placenta increta is when the placenta invades the myometrium, and placenta percreta is when it penetrates through the myometrium and reaches the serosa. These abnormal adherence patterns are associated with risks and complications during pregnancy and delivery, while placenta abruptio is a separate condition related to premature placental separation.