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What is the appropriate intervention for a mother with a third-degree perineal tear postpartum?
- A. Apply ice packs to the perineum
- B. Administer stool softeners as prescribed
- C. Encourage the mother to avoid heavy lifting
- D. Provide perineal exercises for faster recovery
Correct Answer: C
Rationale: The correct answer is C: Encourage the mother to avoid heavy lifting. After a third-degree perineal tear, it is crucial to prevent strain on the perineum to promote healing and prevent complications like infection or further tearing. Heavy lifting can increase pressure on the perineum, leading to delayed healing. Ice packs (A) may help reduce swelling initially but do not address the underlying issue. Stool softeners (B) can help prevent constipation and straining during bowel movements but do not directly impact perineal tear healing. Perineal exercises (D) are beneficial for strengthening the pelvic floor muscles in general but should be introduced gradually and not immediately postpartum with a severe tear.
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In a 28-day menstrual cycle, when does ovulation typically occur?
- A. around day 7
- B. around day 14
- C. around day 21
- D. around day 28
Correct Answer: B
Rationale: The correct answer is B: around day 14. Ovulation typically occurs around day 14 in a 28-day menstrual cycle. This is because ovulation usually happens around 14 days before the start of the next menstrual period. This timing aligns with the midpoint of the menstrual cycle, which is around day 14. Ovulation is the release of an egg from the ovary, marking the most fertile period for conception. Choices A, C, and D are incorrect because ovulation does not typically occur on day 7, day 21, or day 28 in a 28-day menstrual cycle.
A nurse is caring for a client who is 1 hr postpartum and observes a large amount of lochia rubra and several small clots on the client's perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take?
- A. Document the findings and continue to monitor the client.
- B. Notify the client's provider.
- C. Increase the frequency of fundal massage.
- D. Encourage the client to empty her bladder.
Correct Answer: A
Rationale: The correct answer is A: Document the findings and continue to monitor the client. This is the appropriate action because the client's fundus is midline and firm, indicating good uterine tone. Lochia rubra and small clots are expected findings in the immediate postpartum period. The nurse should document these findings for future reference and continue to monitor the client's condition.
Choice B (Notify the client's provider) is incorrect because there are no concerning signs that warrant immediate provider notification, as the fundus is firm and midline.
Choice C (Increase the frequency of fundal massage) is unnecessary since the fundus is already firm at the umbilicus, indicating good uterine tone.
Choice D (Encourage the client to empty her bladder) is not the priority in this scenario, as the client's fundal assessment and lochia observations take precedence.
The nurse is caring for a client in labor with a history of cesarean delivery. What is a priority assessment?
- A. Assess for signs of uterine rupture.
- B. Monitor maternal temperature hourly.
- C. Check for signs of preeclampsia.
- D. Assess for excessive fetal movement.
Correct Answer: A
Rationale: The correct answer is A: Assess for signs of uterine rupture. This is the priority assessment because a history of cesarean delivery puts the client at higher risk for uterine rupture during labor. Signs of uterine rupture include severe abdominal pain, abnormal fetal heart rate patterns, and vaginal bleeding. Early detection and intervention are crucial for the safety of both the mother and the baby. Monitoring maternal temperature (B) is important but not as critical as assessing for uterine rupture. Checking for signs of preeclampsia (C) is also important but not a priority in this specific scenario. Assessing for excessive fetal movement (D) is not a priority assessment in this case.
The nurse provides education to the person undergoing a surgical abortion. What response by the person shows an understanding of the education?
- A. “It’s good I won’t have any pain after the procedure.â€
- B. “I think I’m sure about my decision.â€
- C. “I should call if I soak a pad in 2 hours.â€
- D. “I should follow up for contraception counseling at my annual exam in 6 months.â€
Correct Answer: C
Rationale: The correct answer is C because soaking a pad in 2 hours could indicate excessive bleeding, a potential complication after a surgical abortion. This response shows understanding of the education provided by the nurse about when to seek immediate medical attention.
Choice A is incorrect because it is not true that there will be no pain after a surgical abortion; pain is a common experience post-procedure. Choice B is incorrect because it does not demonstrate an understanding of the key information provided during education. Choice D is incorrect because contraception counseling should be addressed sooner than 6 months post-abortion to prevent unintended pregnancies.
A nurse is caring for a client who is in labor and has a diagnosis of group B streptococcus B-hemolytic infection. Which of the following medications should the nurse plan to administer?
- A. Ampicill in
- B. Azithro mycin
- C. Ceftriax one
- D. Acyclov ir
Correct Answer: A
Rationale: The correct answer is A: Ampicillin. Group B Streptococcus (GBS) infection during labor is typically treated with intravenous antibiotics like ampicillin to prevent transmission to the newborn. Ampicillin is the first-line treatment for GBS during labor due to its effectiveness in eradicating the bacteria and reducing the risk of neonatal infection. Azithromycin (B) is not typically used for GBS infection during labor. Ceftriaxone (C) is not the preferred antibiotic for GBS during labor. Acyclovir (D) is used to treat viral infections, not bacterial infections like GBS.