Nokea
Two hours after delivery the nurse assesses the client and documents that the fundus is soft, boggy, above the level of the umbilicus, and displaced to the right side. The nurse encourages the client to void. Which is the rationale for this nursing action?
- A. A full bladder prevents normal contractions of the uterus.
- B. An overdistended bladder may press against the episiotomy causing dehiscence.
- C. Distention of the bladder can cause urinary stasis and infection.
- D. It makes the client more comfortable when the fundus is massaged.
Correct Answer: A
Rationale: The correct answer is A: A full bladder prevents normal contractions of the uterus. A full bladder can impede the involution process of the uterus by exerting pressure on it, inhibiting proper contraction. This can lead to postpartum hemorrhage and increased risk of retained placental fragments. Encouraging the client to void helps to relieve the pressure on the uterus, allowing it to contract effectively and aiding in the expulsion of lochia and prevention of complications.
Other choices are incorrect because:
B: An overdistended bladder may press against the episiotomy causing dehiscence - While this is a potential risk, it is not directly related to fundal assessment and contraction.
C: Distention of the bladder can cause urinary stasis and infection - While true, this is not the primary concern when assessing the fundus post-delivery.
D: It makes the client more comfortable when the fundus is massaged - Massaging the fundus is a separate intervention and does
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During the active phase of labor, the membranes rupture and the nurse notes green amniotic fluid. Which nursing action should be initiated immediately?
- A. Call the physician.
- B. Replace the soiled underpad.
- C. Test the fluid with pH (Nitrazine) paper.
- D. Assess fetal heart rate.
Correct Answer: D
Rationale: The correct answer is D: Assess fetal heart rate. This is important because green amniotic fluid indicates meconium staining, which can be a sign of fetal distress. Assessing the fetal heart rate immediately will help determine the baby's well-being. Calling the physician (choice A) may be necessary but assessing the fetal heart rate should be the priority. Replacing the underpad (choice B) can wait until after assessing the fetal heart rate. Testing the fluid with pH paper (choice C) may confirm the presence of meconium but assessing the fetal heart rate is more urgent.
A nurse is caring for a child who has hemophilia. The nurse should expect abnormal results in which of the following diagnostic tests?
- A. Fibrinogen
- B. Hemoglobin level
- C. Prothrombin time (PT)
- D. Partial thromboplastin time (PTT)
Correct Answer: D
Rationale: The correct answer is D: Partial thromboplastin time (PTT). In hemophilia, there is a deficiency in specific clotting factors, leading to prolonged PTT due to impaired intrinsic pathway function. A: Fibrinogen level is normal in hemophilia as it is not affected by clotting factor deficiencies. B: Hemoglobin level is unrelated to hemophilia and reflects oxygen-carrying capacity of blood. C: Prothrombin time (PT) evaluates the extrinsic pathway, which is typically normal in hemophilia. Therefore, the abnormal result is in PTT, making it the correct choice.
A nurse is preparing a room for the admission of a client with sickle cell anemia who is in vasoocclusive crisis. Which type of equipment should the nurse place in the client's room?
- A. Wheelchair with adjustable leg rests
- B. A radio and age-appropriate reading materials
- C. Extra blankets and pillows
- D. Blood transfusion equipment
Correct Answer: D
Rationale: The correct answer is D: Blood transfusion equipment. In a vasoocclusive crisis, the client with sickle cell anemia may require blood transfusions to improve oxygen delivery to tissues. Having blood transfusion equipment readily available in the client's room ensures prompt initiation of treatment. Wheelchair (A) and comfort items like extra blankets and pillows (C) are important but not essential during a vasoocclusive crisis. A radio and reading materials (B) are not directly related to the client's immediate medical needs.
A nurse is reinforcing teaching with the parents of an infant diagnosed with recurrent otitis media. Which of the following is appropriate teaching to include?
- A. Give the child an over-the-counter antihistamine when the symptoms begin.
- B. Hold the child in an upright position while feeding.
- C. Talk with the primary health care provider about performing a tonsillectomy.
- D. Apply a warm compress over the affected ear to provide comfort.
Correct Answer: B
Rationale: The correct answer is B: Hold the child in an upright position while feeding. This is important because feeding the infant in an upright position can help prevent reflux of milk into the Eustachian tube, reducing the risk of otitis media. This position helps to promote proper drainage and ventilation of the middle ear, decreasing the likelihood of infection.
Incorrect answers:
A: Giving the child an over-the-counter antihistamine is not appropriate for otitis media, as it is typically caused by bacterial infection, not allergies.
C: Tonsillectomy is not a first-line treatment for otitis media. It is usually considered if the child has recurrent tonsillitis, not otitis media.
D: Applying a warm compress over the affected ear may provide comfort but does not address the underlying cause or prevention of otitis media.
With routine prenatal screening, a woman in the second trimester of pregnancy is confirmed to have gestational diabetes. How may the nurse explain the role of diet and insulin in the management of blood sugar during pregnancy?
- A. You will need to take an oral hypoglycemic, which is a pill to lower your blood sugar.
- B. Insulin lowers an elevated blood sugar during pregnancy to meet the increased metabolic needs of the baby.
- C. There is a good possibility you will be taking insulin for the rest of your life.
- D. You should eat three large meals per day to maintain steady glucose load.
Correct Answer: B
Rationale: The correct answer is B: Insulin lowers an elevated blood sugar during pregnancy to meet the increased metabolic needs of the baby. During pregnancy, the placenta produces hormones that can make it difficult for insulin to work effectively, leading to gestational diabetes. Insulin helps to lower blood sugar levels in the mother, which in turn provides the necessary glucose for the developing baby's growth and development. The other choices are incorrect because: A) Oral hypoglycemics are not typically prescribed during pregnancy due to potential risks to the baby. C) Gestational diabetes usually resolves after delivery and does not require lifelong insulin use. D) Eating three large meals per day can cause blood sugar spikes and is not recommended for managing gestational diabetes.