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What is the first action for a mother experiencing excessive bleeding two hours postpartum?
- A. Monitor blood pressure and heart rate
- B. Perform uterine massage to stimulate contractions
- C. Prepare for a possible blood transfusion
- D. Notify the healthcare provider immediately
Correct Answer: A
Rationale: Uterine massage stimulates contractions, which can reduce postpartum bleeding.
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Three hours after birth, a newborn of a mother with diabetes becomes jittery, has weak, high-pitched cry , and exhibits irregular respirations. The nurse recognizes that these signs are often associated with:
- A. Hypovolemia
- B. Hypocalcemia
- C. Hypoglycemia
- D. Hyperglycemia
Correct Answer: C
Rationale: Hypoglycemia is common in infants of diabetic mothers.
To which client is it most appropriate to recommend the intrauterine device (IUD)?
- A. Unmarried, 22-year-old, recent college graduate.
- B. Married, 24-year-old, G0 P0000.
- C. Unmarried, 25-year-old, history of chlamydia.
- D. Married, 26-year-old, G3 P2102.
Correct Answer: D
Rationale: IUDs are ideal for women in stable relationships with no history of PID.
The nurse is assessing a postpartum client who is breastfeeding. What finding requires further evaluation?
- A. Engorgement on day 3 postpartum.
- B. Mild nipple tenderness.
- C. Cracked and bleeding nipples.
- D. Colostrum present in the first 48 hours.
Correct Answer: C
Rationale: Cracked and bleeding nipples may indicate poor latch or incorrect breastfeeding technique, requiring intervention.
A nurse is assessing a client who is at 27 weeks of gestation and has preeclampsia. Which of the following findings should the nurse report to the provider?
- A. Urine protein concentration 200 mg/ 24 hr.
- B. Creatinine 0.8 mg/ Dl
- C. Hemoglobin 14.8 g/ dL
- D. Platelet Count 60.000/ mm3
Correct Answer: D
Rationale: A platelet count of 60,000/mm3 is significantly low and can be indicative of thrombocytopenia, a potential complication of preeclampsia known as HELLP syndrome (Hemolysis, Elevated Liver enzymes, and Low Platelet count). Thrombocytopenia increases the risk of bleeding complications during pregnancy and delivery, requiring prompt evaluation and management by the healthcare provider. The nurse should report this finding immediately to prevent any adverse outcomes for the client and baby.
The nurse is teaching a prenatal class about breastfeeding. What is a key benefit of colostrum?
- A. It increases the baby’s birth weight.
- B. It provides antibodies that protect against infection.
- C. It eliminates the need for formula supplementation.
- D. It reduces maternal fatigue.
Correct Answer: B
Rationale: Colostrum is rich in antibodies, which provide passive immunity and protect the newborn from infections.