Nokea
The oncoming shift nurse assesses the fundus of the postpartum client 6 hours after a vaginal birth and finds that it is firm. When the nurse then assists the client out of bed for the first time, blood begins to run down the client’s leg. Which action by the nurse in response to the client’s bleeding is correct?
- A. Explain that extra bleeding can occur with initial standing
- B. Immediately assist the client back into bed
- C. Push the emergency call light in the room
- D. Call the HCP to report this increased bleeding
Correct Answer: A
Rationale: Lochia normally pools in the vagina when the postpartum client remains in a recumbent position for any length of time. When the client then stands, gravity causes the blood to flow out. As long as the nurse knows the fundus is firm and not bleeding, a simple explanation to the client is all that is required. There is no reason to return the client to bed; the fundus is firm. There is no reason to push the emergency call light. Increased bleeding is an expected response when standing for the first time. There is no reason to call the HCP.
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The nurse caring for the postpartum client who is 15 years old is concerned about this client’s ability to parent a newborn. Which behavior is characteristic of the developmental level of the 15-year-old that justifies the nurse’s concern?
- A. Developing autonomy
- B. Follows rules established by others
- C. Career oriented
- D. Egocentric
Correct Answer: D
Rationale: The development of autonomy is a developmental task of toddlerhood. School-age children are motivated to follow rules established by others. Adult women are concerned about the effect of childbearing on careers. Although it is biologically possible for the adolescent female to become a parent, her egocentricity and concrete thinking interfere with her ability to parent effectively. Because of this normal development, the adolescent may inadvertently neglect her child.
The nurse identifies which factor as increasing the risk of gestational hypertension?
- A. Low body mass index
- B. Family history of hypertension
- C. First pregnancy at age 20
- D. Vegetarian diet
Correct Answer: B
Rationale: A family history of hypertension increases the risk of gestational hypertension, as genetics play a significant role.
The nurse is caring for the low-risk laboring client during the first stage of labor. When should the nurse assess the FHR pattern? Select all that apply.
- A. Before administering medications
- B. At least every fifteen minutes
- C. After vaginal examinations
- D. During a hard contraction
- E. When giving oxytocin
Correct Answer: A,C
Rationale: The FHR may be affected by medications given to the mother. Therefore, a baseline FHR should be determined before giving any medication to the laboring client and then assessed again after giving the medication. The FHR should be assessed after each vaginal examination because the fetus could change positions, or be stressed by the intrusion of the examiner’s fingers, or intact membranes could have ruptured. The FHR should be assessed every 30 minutes (not 15 minutes) during the first stage of labor if the client is categorized as low risk. The FHR should be assessed every 15 minutes during the second stage of labor. Although the FHR could be listened to during a contraction, it may be difficult due to muffling of the sounds and maternal movement. It is most important to listen before and after the contraction to more accurately detect FHR decelerations. If the client is classified as low risk, she should not be receiving oxytocin (Pitocin) for labor augmentation or induction.
The nurse correctly explains to the group that the discomfort associated with varicose veins is relieved by which activity?
- A. Resting with the feet in a dependent position
- B. Sitting for periods of time when possible
- C. Putting on calf-length, elastic-top hose
- D. Moving around after standing in one position
Correct Answer: C
Rationale: Elastic-top hose improves venous return, reducing discomfort from varicose veins, unlike dependent positioning or sitting.
The client delivered a healthy newborn 4 hours ago after being induced with oxytocin. While being assisted to the bathroom to void for the first time after delivery, the client tells the nurse that she doesn’t feel a need to urinate. Which explanation should the nurse provide when the client expresses surprise after voiding 900 mL of urine?
- A. “A decreased sensation of bladder filling is normal after childbirth.”
- B. “The oxytocin you received in labor makes it difficult to feel voiding.”
- C. “You probably didn’t empty completely. I will need to scan your bladder.”
- D. “Your bladder capacity is large; you likely won’t void again for 6—8 hours.”
Correct Answer: A
Rationale: The nurse should explain about the decreased sensation of bladder filling after childbirth. It is not uncommon for the postpartum client to have increased bladder capacity, decreased sensitivity to fluid pressure, and a decreased sensation of bladder filling. Oxytocin (Pitocin) is not expected to cause a change in bladder sensation, but it does have an antidiuretic effect. There is no indication that the client didn’t completely empty; a volume of 900 mL is a large amount. The postpartum client is at risk for bladder overdistention and should be encouraged to void every 2 to 4 hours.