Which of the following findings should the nurse expect?
- A. Temperature 37.4°C (99.3°F).
- B. Uterine tenderness.
- C. WBC Count 9,000/mm.
- D. Scant lochia.
Correct Answer: B
Rationale: Uterine tenderness is a common finding in endometritis due to uterine inflammation or infection. A temperature of 37.4°C is normal, a WBC count of 9,000/mm³ is not elevated as expected in infection, and scant lochia is normal, not indicative of endometritis.
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Which of the following findings should prompt the nurse to reassess the client?
- A. Intense contractions lasting 45 to 60 seconds.
- B. Progressive sacral discomfort during contractions.
- C. A sense of excitement and warm, flushed skin.
- D. An urge to have a bowel movement during contractions.
Correct Answer: D
Rationale: An urge to have a bowel movement during contractions may indicate the baby's head is descending, signaling the need to push. This requires reassessment to check dilation. Intense contractions, sacral discomfort, and excitement with flushed skin are normal labor findings.
Which of the following actions should the nurse include in the plan of care?
- A. Avoid using lotion or ointment on the newborn's skin.
- B. Dress the newborn in lightweight clothing.
- C. Keep the newborn supine throughout treatment.
- D. Measure the newborn's temperature every 6 hr.
Correct Answer: A
Rationale: Avoiding lotion or ointment ensures effective bilirubin breakdown during phototherapy. Clothing reduces skin exposure, supine positioning is not required, and temperature monitoring is routine but not specific to phototherapy.
The nurse should anticipate the use of which of the following medications?
- A. Betamethasone.
- B. Hydralazine.
- C. Terbutaline.
- D. Methylergonovine.
Correct Answer: D
Rationale: Methylergonovine is an uterotonic used to treat uterine atony by promoting contractions to control bleeding when oxytocin fails. Betamethasone aids fetal lung maturity, hydralazine treats hypertension, and terbutaline relaxes the uterus.
Which of the following actions should the nurse include in the plan of care?
- A. Administer broad-spectrum antibiotics.
- B. Monitor the rectal temperature every 4 hr.
- C. Cleanse the site with povidone-iodine.
- D. Prepare for surgical closure after 72 hr.
Correct Answer: A
Rationale: Administering broad-spectrum antibiotics prevents infection, critical due to the risk of meningitis from leaking cerebrospinal fluid. Temperature monitoring is secondary, povidone-iodine is harmful to neural tissue, and surgery is typically within 24-48 hours.
Which of the following actions should the nurse take first?
- A. Offer the client a sitz bath.
- B. Insert a urinary catheter.
- C. Assist the client to the bathroom.
- D. Pour warm water over the client's perineum.
Correct Answer: C
Rationale: Assisting the client to the bathroom encourages natural voiding to relieve bladder distention, the first step to avoid invasive measures. Sitz baths, catheterization, or warm water are secondary if voiding fails.