Nokea
Two days after delivery, a postpartum client prepares for discharge. What should the nurse teach her about lochia flow?
- A. Lochia does change color but goes from lochia rubra (bright red) on days 1-3, to lochia serosa (pinkish brown) on days 4-9, to lochia alba (creamy white) days 10-21.
- B. Numerous clots are abnormal and should be reported to the physician.
- C. Saturation of the perineal pad is considered abnormal and may indicate postpartum hemorrhage.
- D. Lochia normally lasts for about 21 days, and changes from a bright red, to pinkishbrown, to creamy white.
Correct Answer: D
Rationale: The correct answer is D. Lochia normally lasts for about 21 days, and changes from bright red to pinkish-brown to creamy white. This is accurate because the process of lochia flow typically follows this pattern as the uterus sheds its lining post-delivery. Lochia rubra occurs in the first few days due to blood, then transitions to serosa and alba as the bleeding decreases. Choice A is incorrect as it presents the correct information but in a confusing manner. Choices B and C are incorrect because they focus on abnormal findings rather than the normal progression of lochia.
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At 28 weeks gestation, a woman enters the hospital in preterm labor and receives atocolytic medication to stop labor. Which assessment findings should be reported immediately to the physician?
- A. Fetal heart rate averaging 160 beats/min
- B. Irregular contractions every 15-20 minutes that last 30 seconds before stopping
- C. Maternal temperature 98.8 degrees F, pulse 84, respiratory rate 22, BP 130/70
- D. Ferning pattern of vaginal discharge under a microscope
Correct Answer: D
Rationale: The correct answer is D - Ferning pattern of vaginal discharge under a microscope. This finding indicates rupture of membranes which can lead to infection and necessitates immediate medical attention to prevent harm to the fetus and mother. A: Fetal heart rate of 160 bpm is within normal range. B: Irregular contractions every 15-20 minutes are not indicative of active labor. C: Maternal vital signs are within normal limits and do not pose an immediate threat.
In a child diagnosed with Tetralogy of Fallot, which of the following is a compensatory mechanism to decrease venous return to the heart?
- A. Squatting
- B. Clubbing
- C. Shortness of breath
- D. Polycythemia
Correct Answer: A
Rationale: Squatting is a compensatory mechanism that decreases venous return (deoxygenated blood) to the heart. This clinical sign is commonly seen in young children with Tetralogy of Fallot, a type of cyanotic heart disease. Squatting helps reduce the workload on the heart by decreasing the amount of deoxygenated blood returning to it.
Shortly after delivery, the nursery nurse gives the newborn an injection of phytonadione (Vitamin K). The infant's grandmother wants to know why the baby got 'a shot in his leg.' Which response by the nurse is most appropriate?
- A. Vitamin K promotes bone and muscle growth.
- B. Vitamin K helps the baby digest milk.
- C. Vitamin K helps stabilize the baby's blood sugar.
- D. Vitamin K is used to prevent bleeding.
Correct Answer: D
Rationale: The correct answer is D: Vitamin K is used to prevent bleeding. Shortly after birth, newborns have low levels of Vitamin K, which is essential for blood clotting. Administering phytonadione helps prevent a rare but serious condition called Vitamin K deficiency bleeding. Option A is incorrect as Vitamin K primarily supports blood clotting, not bone and muscle growth. Option B is incorrect as Vitamin K does not aid in digestion. Option C is incorrect as Vitamin K does not directly affect blood sugar stabilization.
A nurse is caring for a client who is in active labor and has had no cervical change in the last 4 hr. Which of the following statements should the nurse make?
- A. Let me help you into a comfortable pushing position so you can begin bearing down.
- B. I am going to call the doctor to get a prescription for medication to ripen your cervix.
- C. I will give you some IV pain medicine to strengthen your contractions.
- D. Your provider will insert an intrauterine pressure catheter to monitor the strength of your contractions.
Correct Answer: D
Rationale: The correct answer is D. The nurse should inform the client about the provider inserting an intrauterine pressure catheter to monitor contraction strength. This is appropriate because lack of cervical change in active labor could indicate inadequate contractions. Monitoring contraction strength with an intrauterine pressure catheter can help determine if the contractions are effective in progressing labor. It allows for more accurate assessment and timely interventions if needed.
Choice A is incorrect because pushing without adequate cervical dilation can lead to complications. Choice B is incorrect as medication to ripen the cervix is not indicated in this scenario. Choice C is incorrect as IV pain medicine does not address the issue of inadequate cervical change.
A client, gravida 1, para 0, in active labor, is becoming increasingly anxious. Which statement by the nurse will block therapeutic communication with the client?
- A. What concerns are you having now?
- B. Tell me how you are feeling.
- C. Everything is going just fine.
- D. You seem a little nervous.
Correct Answer: C
Rationale: Correct Answer: C
Rationale:
1. Choice A and B encourage the client to express their concerns and feelings, promoting therapeutic communication.
2. Choice D acknowledges the client's emotions, showing empathy and understanding.
3. Choice C dismisses the client's anxiety, invalidating their feelings, hindering communication.
Summary:
Choices A, B, and D promote open communication and empathy, while choice C ignores the client's anxiety, making it the incorrect choice.