Nokea
Which assessment finding would lead the nurse to suspect a postpartum hemorrhage? Blood loss of _____.
- A. less than 300 ml/24 hours
- B. more than 400 ml/24 hours
- C. less than 200 ml/2 hours
- D. more than 500 m2/24 hours
Correct Answer: D
Rationale: Postpartum hemorrhage is defined as a blood loss of more than 500 ml within the first 24 hours after vaginal delivery or more than 1000 ml following a cesarean delivery. Excessive bleeding can lead to hypovolemic shock and can be life-threatening if not promptly addressed. Therefore, a blood loss of more than 500 ml/24 hours would lead the nurse to suspect a postpartum hemorrhage and prompt further assessment and intervention.
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A 22-year-old woman presents with cyclic pelvic pain, dysmenorrhea, and infertility. On pelvic examination, the uterus is retroverted and enlarged. Which of the following conditions is most likely to be responsible for these findings?
- A. Endometriosis
- B. Adenomyosis
- C. Leiomyomas (uterine fibroids)
- D. Pelvic inflammatory disease (PID)
Correct Answer: B
Rationale: Adenomyosis is a condition characterized by the presence of endometrial tissue within the myometrium (muscle wall) of the uterus. It can present with symptoms such as cyclic pelvic pain, dysmenorrhea (painful periods), and infertility. On pelvic examination, the uterus may be retroverted (tilted backward) and enlarged due to the presence of adenomyotic nodules within the uterine muscle. Adenomyosis can also cause heavy menstrual bleeding (menorrhagia). Endometriosis, on the other hand, involves the presence of endometrial tissue outside the uterus and can cause similar symptoms but is less likely to result in uterine enlargement or retroversion. Leiomyomas (uterine fibroids) are benign tumors of the uterine muscle and can also cause pelvic pain and abnormal uterine enlargement but are less likely to be associated with dysmenorrhea and infertility
Nurse Addison provides instructions about measures to prevent postpartum mastitis who is breast feeding her newborn. Which of the following would indicate that the mother needs further instruction? "I Should _______."
- A. wash my hands wel1 before breastfeeding
- B. breastfeed every 2-3 hours
- C. change the breast pads frequently
- D. wash my nipples with s0ap and water prior to feeding 3 hours
Correct Answer: D
Rationale: Nursing mothers should not wash their nipples with soap and water prior to feeding. Using soap can dry out the skin and potentially lead to irritation or cracking of the nipple, which can increase the risk of mastitis. It is recommended to simply clean the nipples with water, if necessary.
Nurse Vera informs the patient she should be screened for pre-eclmapsia during this term of pregnancy_______.
- A. first
- B. Third
- C. second
- D. Before delivery
Correct Answer: A
Rationale: Pre-eclampsia is a serious condition that can occur during pregnancy, usually after 20 weeks gestation. It is important to screen for pre-eclampsia early in the pregnancy to monitor and manage the condition effectively. Screening for pre-eclampsia typically begins in the first trimester of pregnancy to identify any risk factors and provide appropriate care for the patient. Therefore, Nurse Vera informing the patient to get screened for pre-eclampsia in the first term of pregnancy is the most appropriate time to start monitoring for this condition.
Which danger sign would warrant stoppage of pills?
- A. Clear vision
- B. Decrease blood pressure
- C. Simple colds
- D. Elevation of blood pressure
Correct Answer: D
Rationale: An elevation of blood pressure would warrant stoppage of pills. High blood pressure, or hypertension, in a 4-year-old child is abnormal and needs prompt medical attention. Giving pills without monitoring or stopping them if blood pressure is elevated can lead to serious health complications. It is important to address the underlying cause of high blood pressure in a child, which may require further evaluation and management by a healthcare provider.
Romy is diagnosed with small cell lung cancer (SCLC) a rapidly growing type of cancer. He and his family were shocked when told by the doctor that the patient will just undergo palliative treatment. Which nursing action is MOST APPROPRIATE?
- A. Providing relief from symptoms.
- B. Reducing fatigue
- C. Providing psychological support.
- D. Advising treatment options
Correct Answer: A
Rationale: In the case of Romy being diagnosed with small cell lung cancer (SCLC) and undergoing palliative treatment, the most appropriate nursing action is to focus on providing relief from symptoms. Palliative care aims to improve the quality of life for patients with serious illnesses by managing their symptoms, such as pain, shortness of breath, nausea, and other side effects of treatment. As the cancer is advanced and the goal is not curative treatment but rather to keep the patient comfortable, symptom management becomes a priority to ensure Romy's physical comfort and well-being during this difficult time. Providing relief from symptoms is crucial in palliative care to help enhance the patient's quality of life and ensure they are as comfortable as possible.