Nokea
Early postpartum woman
Which maternal event is abnormal in the early postpartum period?
- A. Lochial color changes from rubra to alba.
- B. Extreme hunger and thirst.
- C. Diuresis and diaphoresis.
- D. Flatulence and constipation.
Correct Answer: B
Rationale: Extreme hunger and thirst may indicate abnormal blood sugar levels or metabolic issues, requiring further evaluation, unlike the other normal postpartum events.
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Client after amniotomy
After an amniotomy, which action by the nurse takes priority?
- A. Change the patient's gown.
- B. Assess the fetal heart rate.
- C. Estimate the amount of amniotic fluid.
- D. Assess the color of the amniotic fluid.
Correct Answer: B
Rationale: Assessing the fetal heart rate is the priority after an amniotomy to ensure the fetus tolerates the procedure and detect any distress.
Vacuum extraction birth
While assisting with a vacuum extraction birth, what should the nurse immediately report to the physician?
- A. Maternal pulse rate of 100 bpm.
- B. Maternal blood pressure of 120/70 mm Hg.
- C. Decrease in intensity of uterine contractions.
- D. Persistent fetal bradycardia below 100 bpm.
Correct Answer: D
Rationale: Persistent fetal bradycardia below 100 bpm indicates potential fetal distress, requiring immediate reporting to ensure fetal safety.
Client receiving opioid epidural analgesia during labor
A nurse is caring for a client who is receiving opioid epidural analgesia during labor. Which of the following findings is the nurse's priority?
- A. Blood pressure 80/56 mm Hg.
- B. The client reports profuse itching.
- C. The client reports weakness of the lower extremities.
- D. Temperature 38.2°C (100.8 F).
Correct Answer: A
Rationale: Hypotension (80/56 mm Hg) is the priority as it can reduce placental blood flow, risking fetal distress, and requires immediate intervention.
Primigravida client in second stage of labor, moaning and screaming, husband requests pain medication
A primigravida client in the second stage of labor has been moaning, screaming, and generally vocal throughout her labor. Her husband is distraught seeing his wife this way and asks the nurse for more pain medication for her. What is the nurse's best response?
- A. Assist the client with breathing and imagery techniques in an attempt to calm her down.
- B. Ask the client to describe the intensity of her pain on a scale of 0 to 10.
- C. Page the obstetrician to evaluate the client's pain, and administer an appropriate increase in her pain medication.
- D. Reassure the first-time father that his wife will be fine, and offer to stay with her while he takes a walk.
Correct Answer: A
Rationale: Assisting with breathing and imagery techniques provides nonpharmacological pain relief and supports the client's coping mechanisms, which is appropriate as vocalizing is a normal way to express pain during labor.
New mother, postpartum period
Choose the sign or symptom that a new mother should be taught to report:
- A. Occasional uterine cramping when the infant nurses.
- B. Descent of the fundus one fingerbreadth each day.
- C. Reappearance of red lochia after it changes to serous.
- D. Oral temperature that is 37.2 C (99 F) in the morning.
Correct Answer: C
Rationale: Reappearance of red lochia after it becomes serous may indicate uterine atony or retained placental fragments, requiring immediate reporting.