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A nurse is caring for a client who had a vaginal delivery 4 hours 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. Apply a corticosteroid cream to the perineal area twice daily.
- C. Offer an ice pack to the client during the first 24 hours.
- D. Increase the client's fluid intake for 48 hours.
Correct Answer: C
Rationale: Offering an ice pack reduces swelling and numbs perineal pain, a standard intervention within the first 24 hours post-delivery.
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A charge nurse is discussing risk factors for postpartum hemorrhage with a newly licensed nurse.
Which of the following conditions should the nurse include as a risk factor?
- A. Oligohydramnios.
- B. Breech presentation.
- C. Retained placental fragments.
- D. Urinary tract infection.
Correct Answer: C
Rationale: Retained placental fragments prevent uterine contraction, a significant risk factor for postpartum hemorrhage.
The nurse should first address the client's blood pressure followed by the client's platelet count.
Which of the following options correctly prioritizes these actions?
- A. Blood pressure should be checked before platelet count.
- B. Platelet count is more important than blood pressure.
- C. Address both simultaneously.
- D. Ignore blood pressure.
Correct Answer: A
Rationale: Blood pressure should be checked first as it indicates immediate hemodynamic status, critical in acute settings, followed by platelet count for bleeding risk.
A nurse is reinforcing discharge teaching about home safety with a client who is postpartum.
In which of the following positions should the nurse instruct the client to place their newborn in the crib?
- A. Supine.
- B. Left lateral.
- C. Right lateral.
- D. Prone.
Correct Answer: A
Rationale: Placing a newborn in the supine position (on their back) is recommended to reduce the risk of sudden infant death syndrome (SIDS), a proven safe sleep practice.
The nurse is collecting data from the client 24 hr later.
How should the nurse interpret the findings?
- A. Moderate lochia rubra: Sign of potential improvement.
- B. Client reports decreased level of pain: Sign of potential improvement.
- C. Temperature 38.4°C (101°F): Sign of potential worsening condition.
- D. WBC count 15,000/mm³ : Sign of potential worsening condition.
Correct Answer: C
Rationale: A temperature of 38.4°C (101°F) suggests a potential infection or inflammatory process, indicating a worsening condition.
A nurse is reinforcing teaching with a client about various contraceptive methods.
Which of the following statements should the nurse include in the teaching?
- A. You will need to receive a medroxyprogesterone acetate injection once per month.
- B. Combined estrogen-progestin contraceptive pills cause longer periods.
- C. You will need to have your diaphragm replaced every 4 years.
- D. Oral contraceptives decrease the risk for endometrial cancer.
Correct Answer: D
Rationale: Oral contraceptives decrease the risk for endometrial cancer by preventing thickening of the uterine lining, offering a protective effect with prolonged use.