Nokea
Which circumstance is most likely to cause uterine partum assessment with a woman who is 4 days atony and lead to excessive blood loss?
- A. Orthostatic hypotension
- B. Involution of the uterus
- C. Urine retention
- D. Afterpains
Correct Answer: A
Rationale: Orthostatic hypotension, which is a sudden drop in blood pressure upon standing, can result in decreased perfusion to the uterus, leading to poor contraction of the uterine muscles. This can result in uterine atony, where the uterus fails to contract properly after delivery. Uterine atony is a common cause of excessive postpartum bleeding (postpartum hemorrhage). Without proper contraction of the uterus, the blood vessels that supplied the placenta during pregnancy remain open and bleeding can continue unchecked.
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The nurse is monitoring a client with suspected placental abruption. What is a key assessment finding?
- A. Painless vaginal bleeding.
- B. Hard, rigid abdomen with severe pain.
- C. Clear amniotic fluid.
- D. Regular uterine contractions.
Correct Answer: B
Rationale: A hard, rigid abdomen and severe pain are classic signs of placental abruption, requiring urgent intervention.
During a nursing assessment the woman with rupture
- A. What is the nurse's priority action?
- B. Use gravity and manipulation to relieve compression of the cord (butt up in the air and face down until ready to delivery)
- C. Help the fetal head descend faster
- D. Facilitate dilation of the cervix with prostaglandin gel
Correct Answer: A
Rationale: In the scenario presented, the nurse's priority action should be to call for emergent medical assistance. A woman with a rupture during a nursing assessment could be experiencing a serious complication known as umbilical cord prolapse. This occurs when the umbilical cord slips through the cervix ahead of the baby, which can lead to compression of the cord and a serious decrease in oxygen supply to the baby. It is a medical emergency that requires immediate intervention by the healthcare team, which may include moving the mother into a knee-chest position or performing a cesarean section. Therefore, the priority action for the nurse is to ensure prompt medical intervention to protect the well-being of both the mother and the baby.
The nurse is monitoring a client during the second stage of labor. What finding indicates that birth is imminent?
- A. Client reports the urge to push.
- B. Contractions are irregular.
- C. Fetal heart rate is 140 beats/minute.
- D. Cervix is dilated to 8 cm.
Correct Answer: A
Rationale: The urge to push is a sign that the baby is descending, indicating that delivery is near.
What is the primary reason for administering Rh immunoglobulin to an Rh-negative mother after delivery?
- A. To prevent maternal sensitization in future pregnancies
- B. To treat postpartum hemorrhage
- C. To reduce the risk of infection
- D. To boost maternal immune response
Correct Answer: A
Rationale: Rh immunoglobulin prevents maternal sensitization to Rh-positive blood.
A patient is taking oral contraceptives and asks whether they will still be effective if she has diarrhea. What should the nurse respond?
- A. Oral contraceptives will still work if taken with food.
- B. Oral contraceptives may be less effective during diarrhea due to absorption issues.
- C. Oral contraceptives need to be stopped for 7 days when experiencing diarrhea.
- D. Oral contraceptives will be more effective during diarrhea due to faster metabolism.
Correct Answer: B
Rationale: Diarrhea can reduce the absorption of oral contraceptives, potentially making them less effective. Choice A is incorrect because food does not always affect oral contraceptive absorption. Choice C is incorrect because there is no need to stop the contraceptives, but additional methods may be recommended during diarrhea. Choice D is incorrect because diarrhea does not increase the effectiveness of oral contraceptives.