Nokea
A nurse is assisting with the care of a client who is in labor and has an epidural infusion for pain management. The client's blood pressure is 80/40 mm Hg.
Which of the following actions should the nurse take?
- A. Place the client in knee-chest position.
- B. Give a bolus of lactated Ringer's.
- C. Administer methylergonovine IM.
- D. Assist the client to empty her bladder.
Correct Answer: B
Rationale: Giving a bolus of lactated Ringer's solution can help increase the client's blood pressure by expanding the intravascular volume, a common intervention for hypotension caused by epidural anesthesia.
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A nurse is contributing to the plan of care for a client who is postpartum and has mastitis.
Which of the following actions should the nurse plan to take?
- A. Encourage the client to continue to breastfeed.
- B. Prepare the client for an abdominal sonogram.
- C. Encourage the client to wear a loose-fitting bra.
- D. Limit the client's daily fluid intake.
Correct Answer: A
Rationale: Encouraging the client to continue to breastfeed helps empty the breast, reducing pain and inflammation and promoting healing from mastitis.
A nurse is reinforcing teaching about car seat safety with a parent of a newborn.
Which of the following statements by the parent indicates an understanding of the teaching?
- A. I can turn the car seat so it faces forward when my baby weighs 15 pounds.
- B. I will place a thick soft pad behind my baby's back.
- C. I should place my baby in the car seat at a 90-degree angle.
- D. I will place the retainer clip at the level of my baby's armpit.
Correct Answer: D
Rationale: Placing the retainer clip at the armpit level ensures proper harness positioning, distributing crash forces safely across the baby’s chest and shoulders.
A nurse is contributing to the plan of care for a newborn who requires phototherapy for hyperbilirubinemia.
Which of the following interventions should the nurse recommend including in the plan?
- A. Reposition the newborn every 2 hours.
- B. Give the newborn 30 ml of distilled water after each feeding.
- C. Monitor the newborn's blood glucose level every hour.
- D. Apply a water-based ointment to the newborn's skin every 6 hours.
Correct Answer: A
Rationale: Repositioning the newborn every 2 hours ensures even exposure to phototherapy light, preventing skin breakdown and effectively reducing bilirubin levels.
A nurse is reinforcing teaching about outpatient resources for a client who is recovering from a molar pregnancy.
Which of the following statements by the client indicates an understanding of the teaching?
- A. I will need to start chemotherapy immediately.
- B. I will need home palliative services after I am discharged.
- C. I will need to attend a support group when I get home.
- D. I will need an amniocentesis within 1 month.
Correct Answer: C
Rationale: Attending a support group aids emotional recovery after a molar pregnancy, indicating understanding of psychosocial support needs.
Nurses' Notes (Postpartum Assessment) 1200: The client successfully delivered a viable newborn via vaginal delivery. 1300: The client reports feeling tired and anxious. Assessment reveals the fundus is deviated to the left, boggy, and located 1 cm above the umbilicus. The perineal pad is saturated with lochia rubra, indicating excessive bleeding. The client reports an inability to ambulate to the bathroom due to residual numbness from the labor epidural. Pain is reported as 0 on a scale of 0 to 10. Fundal massage performed during assessment has yielded no improvement in uterine tone. A nurse is caring for a 36-year-old female client in the labor and delivery unit at 39 weeks of gestation admitted for evaluation of postpartum bleeding following a vaginal delivery.
Select the 2 interventions the nurse should perform immediately.
- A. Weigh the client’s perineal pad.
- B. Insert a straight catheter for the client.
- C. Administer methylergonovine 0.2 mg IM.
- D. Draw a complete blood count.
- E. Apply oxygen via nasal cannula.
Correct Answer: B,C
Rationale: Inserting a catheter empties the bladder, aiding uterine contraction; methylergonovine stimulates contractions to reduce bleeding from a boggy uterus.