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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Which activity should the nurse recommend to prepare for labor?
- A. Practicing relaxation and breathing techniques
- B. Increasing caffeine intake
- C. Avoiding all physical activity
- D. Taking daily hot baths
Correct Answer: A
Rationale: Practicing relaxation and breathing techniques helps manage labor pain and prepares the client for childbirth.
When looking in the mirror at her abdomen, the postpartum client says to the nurse, “My stomach still looks like I’m pregnant!” The nurse explains that the abdominal muscles, which separate during pregnancy, will undergo which change?
- A. Regain tone Within the first week after birth
- B. Regain prepregnancy tone with exercise
- C. Remain separated, giving the abdomen a slight bulge
- D. Regain tone as the weight gained during pregnancy is lost
Correct Answer: B
Rationale: For most women, it takes about 6 weeks (not one week) to regain abdominal wall muscle tone to the prepregnancy state, and usually only with exercise. The “still-pregnant” appearance is caused by relaxation of the abdominal wall muscles. With exercise, most women can regain prepregnancy abdominal muscle tone within about 6 weeks. If the client delivers a very large infant, the abdominal muscles may separate, but the separation will become less apparent over time. Weight loss alone will not strengthen the abdominal muscles.
The nurse is providing nutrition counseling to a primigravida who is 10 weeks pregnant. Which meal choice stated by the client indicates she needs additional information?
- A. Black beans, wild rice, collard greens
- B. Dry cereal, milk, dried cranberries
- C. Tuna, broccoli, baked potato
- D. Beef strips, lentils, red peppers
Correct Answer: C
Rationale: Tuna contains mercury and should be limited in pregnancy due to risk of mercury poisoning. The nurse should provide this additional information. Black beans provide a good source of calcium, iron, and protein. Black beans, wild rice, and collard greens provide fiber. Collard greens provide a good source of calcium and folic acid. Dry cereal provides a good source of vitamin D, milk provides a good source of calcium, and dried cranberries provide a good source of calcium and iron. Beef provides a good source of protein and iron, lentils provide a good source of iron, and red peppers provide a good source of vitamin C.
Which pregnant client should the nurse encourage to undergo hepatitis B testing?
- A. A client with a history of cigarette smoking
- B. A client who is a health care worker
- C. A client who emigrated in the past year from Haiti
- D. A client who was recently exposed to Haemophilus influenzae
Correct Answer: C
Rationale: Clients from high-prevalence areas like Haiti are at higher risk for hepatitis B, warranting testing during pregnancy.
The primiparous client, who is bottle feeding her infant, asks the nurse when she can expect to start having her menstrual cycle again. Which response by the nurse is most accurate?
- A. “Most women who bottle feed can expect their period within 6 to 10 weeks after birth.”
- B. “Your period should return a few days after your lochial discharge stops.”
- C. “Your lochia will change from pink to white; when white, your period should return.”
- D. “Bottle feeding delays the return of a normal menstrual cycle until 6 months postbirth.”
Correct Answer: A
Rationale: In nonlactating women, the average time to first ovulation is 45 days, and the return of menstruation usually happens within 6 to 10 weeks postbirth. Most women can expect to have lochial discharge for up to 24 days. However, the cessation of discharge is not related to the return of menstruation. The change in lochial color is not related to the return of menstruation. The return of ovulation and menstruation is associated with a rise in serum progesterone levels. Bottle feeding does not affect when this change occurs in the client’s body.