Nokea
Twelve hours after a vaginal delivery with epidural anesthesia, the nurse palpates the fundus of a primiparous client and finds it to be firm, above the umbilicus, and deviated to the right. Which of the following would the nurse do next?
- A. Document this as a normal finding in the client's record.
- B. Contact the physician for an order for methylergonovine.
- C. Encourage the client to ambulate to the bathroom and void.
- D. Gently massage the fundus to expel the clots.
Correct Answer: C
Rationale: A deviated, elevated fundus suggests bladder distention, which can be relieved by voiding.
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A nurse is counseling a client about the use of a diaphragm for contraception. Which of the following instructions should the nurse include?
- A. Insert the diaphragm up to 6 hours before intercourse.
- B. Remove the diaphragm immediately after intercourse.
- C. Use a spermicide with the diaphragm for each act of intercourse.
- D. Store the diaphragm in a dry, airtight container.
Correct Answer: C
Rationale: Using spermicide with the diaphragm for each act of intercourse is essential for effectiveness. The diaphragm can be inserted up to 6 hours before and left in place for at least 6 hours after intercourse but not more than 24 hours. It should be stored in a clean, dry container, not necessarily airtight.
A primigravid client at 30 weeks' gestation has been admitted to the hospital with premature rupture of the membranes without contractions. Her cervix is 2 cm dilated and 50% effaced. The nurse should next assess the client's:
- A. Red blood cell count.
- B. Degree of discomfort.
- C. Urinary output.
- D. Temperature.
Correct Answer: D
Rationale: Temperature should be assessed to monitor for infection.
The nurse on a mother-baby unit who is working on the night shift is revising the planning worksheet for the remaining 2 hours of the shift. The nurse has the following tasks and orders to complete prior to the 7 a.m. change of shift. Using the work plan below, how should the nurse organize the following tasks so that everything is completed by 7 a.m.?
- A. Draw blood for the ordered laboratory tests (CBCs) on 3 postpartum clients with report on charts by shift change.
- B. Start IV of D5 1/2 NS at keep vein open (KVO) rate on postpartum client just prior to change of shift.
- C. Complete admission assessment of newborn turned over to nurse at 5 a.m.
- D. Draw newborn bilirubin level at 6 a.m.
Correct Answer: A,C,D,B
Rationale: 5:00 - Complete admission assessment; 5:30 - Draw CBCs; 6:00 - Draw bilirubin; 6:30 - Start IV. This ensures timely completion.
Which of the following would the nurse include in the teaching plan for a 16-year-old primigravid client in early labor concerning active relaxation techniques to help her cope with pain?
- A. Relaxing uninvolved body muscles during uterine contractions.
- B. Practicing being in a deep, meditative, sleeplike state.
- C. Focusing on an object in the room during the contractions.
- D. Breathing rapidly and deeply between contractions.
Correct Answer: A
Rationale: Active relaxation involves consciously relaxing uninvolved muscles (e.g., face, arms) during contractions to conserve energy and reduce tension, aiding pain management. Meditation is less practical during active labor, focusing on an object is a distraction technique, and rapid breathing between contractions may cause hyperventilation.
The nurse is caring for a multiparous client 48 hours after cesarean delivery. Which finding indicates a potential complication?
- A. Clear urine output via catheter.
- B. Incisional pain relieved by medication.
- C. Scant lochia serosa.
- D. Homan's sign negative bilaterally.
Correct Answer: C
Rationale: Scant lochia serosa at 48 hours may indicate retained clots or infection, requiring further assessment.