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A nurse is caring for a client who had a vaginal delivery 4 hr ago and reports perineal pain of 6 on a scale of 0 to 10.
Which of the following actions should the nurse take?
- A. Catheterize the client's bladder
- B. Offer an ice pack to the client during the first 24 hrs
- C. Apply a corticoid cream to the perineal area twice daily
- D. Increase the client's fluid intake for 48 hrs
Correct Answer: B
Rationale: Ice packs reduce perineal swelling and pain within the first 24 hours post-delivery.
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History and Physical: Repeat caesarean birth 3 days ago, mastitis. Vital Signs: BP 130/84 mm Hg, HR 106/min, RR 20/min, Temp 38.94°C. Assessment: WBC 28,000/mm3, Hgb 13 g/dL, Hct 37%, redness/warmth in left breast, cracked nipples, body aches, chills, headache, breast tenderness.
The nurse is collecting data from the client 24 hr later. How should the nurse interpret the findings?
- A. Purulent nipple discharge: Sign of potential worsening condition
- B. Moderate lochia rubra: Unrelated to diagnosis
- C. Client reports decreased level of pain: Sign of potential improvement
- D. WBC count 35,000/mm3: Sign of potential worsening condition
- E. Temperature 38.4° C (101.1° F): Sign of potential improvement
- F. Hgb 12 g/dL: Unrelated to diagnosis
Correct Answer: A,C,D,E
Rationale: Purulent discharge and increased WBC suggest worsening mastitis, while decreased pain and lower temperature indicate improvement. Lochia and hemoglobin are unrelated to mastitis.
A nurse is reinforcing teaching with a client who is at 10 weeks of gestation regarding the purposes of laboratory tests.
Which of the following statements by the client indicates an understanding of the teaching?
- A. Urine specific gravity identifies my risk for pregnancy-induced hypertension.
- B. White blood cell count is an indicator of anemia.
- C. Platelet count identifies if I am at risk for bleeding.
- D. Sedimentation rate checks for signs of cancer.
Correct Answer: C
Rationale: Platelet count assesses clotting function, identifying bleeding risk in conditions like gestational thrombocytopenia.
A nurse is assisting with the care of a newborn who has neonatal abstinence syndrome.
Which of the following actions should the nurse take first?
- A. Swaddle the newborn in blankets
- B. Determine the newborn's respiratory rate
- C. Auscultate the newborn's bowel sounds.
- D. Weigh the newborn's wet diaper
Correct Answer: B
Rationale: Determining respiratory rate is the priority to assess for distress, as neonatal abstinence syndrome can cause tachypnea.
A nurse in a provider's office is collecting data from a client who is at 34 weeks of gestation and reports having a sudden gush of vaginal fluid.
Which of the following manifestations is the priority?
- A. Fetal heart tones 98 /min
- B. Foul smelling vaginal discharge
- C. Amniotic fluid with meconium noted
- D. Maternal temperature 38.3°C (101°F)
Correct Answer: A
Rationale: Fetal bradycardia (98/min) indicates distress, requiring immediate intervention due to possible cord prolapse after membrane rupture.
A nurse is assisting with the care of a client who is in labor and has received nalbuphine hydrochloride.
Which of the following manifestations should the nurse identify as an adverse effect of this medication?
- A. Fever
- B. Diuresis
- C. Diarrhea
- D. Sedation
Correct Answer: D
Rationale: Sedation is a common adverse effect of nalbuphine, an opioid analgesic, causing drowsiness or reduced alertness.