Nokea
Client 4 hours postpartum, vaginal birth, saturated perineal pad within 10 minutes
Which of the following is the nurse's first action?
- A. Observe for pooling of blood under the buttocks.
- B. Assess client's blood pressure.
- C. Prepare to administer a prescribed oxytocic preparation.
- D. Massage the client's fundus.
Correct Answer: D
Rationale: The correct answer is D: Massage the client's fundus. This is the nurse's first action after childbirth to prevent postpartum hemorrhage by promoting uterine contractions and expelling any clots. Assessing blood pressure (B) is important but not the first action. Observing for pooling of blood under the buttocks (A) is a sign of excessive bleeding but not the first action. Administering oxytocic preparation (C) can help prevent postpartum hemorrhage, but it is not the first action.
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Postpartum client, large amount of lochia rubra with several clots on perineal pad
Which of the following actions should the nurse take first?
- A. Measure the client's vital signs.
- B. Check the client's fundus.
- C. Feel for a full bladder.
- D. Request the provider perform a vaginal examination.
Correct Answer: B
Rationale: The correct action the nurse should take first is to check the client's fundus. This is prioritized because assessing the fundus helps determine the status of postpartum uterine involution and can indicate any signs of hemorrhage. By checking the fundus first, the nurse can promptly identify and address any abnormalities or complications. Measuring vital signs and feeling for a full bladder are important assessments but come after checking the fundus. Requesting a provider perform a vaginal examination is not the first action to take unless there are specific concerns or indications for it.
Client immediate postoperative period, removal of ectopic pregnancy via salpingostomy
The nurse should prepare to administer Rho(D) immune globulin (RhoGAM or RhiG) as prescribed if the record indicates that the client
- A. has previously given birth to an Rh-negative infant.
- B. has had significant blood loss during the procedure.
- C. has expressed a desire to conceive again.
- D. is Rh-negative.
Correct Answer: D
Rationale: The correct answer is D because Rho(D) immune globulin is administered to Rh-negative mothers to prevent hemolytic disease of the newborn in future pregnancies with Rh-positive infants. Choice A is incorrect because having an Rh-negative infant does not warrant the administration of RhoGAM. Choice B is incorrect because significant blood loss does not relate to the need for RhoGAM. Choice C is incorrect as the desire to conceive again does not indicate the necessity for RhoGAM administration.
Client pregnant, BMI of 26.5
Which of the following statements is an appropriate response by the nurse?
- A. A gain of about 25 to 35 pounds is best for you and for your baby.
- B. The recommendation for you is about 15 to 25 pounds.
- C. You should gain 11 to 20 pounds.
- D. It really doesn't matter exactly how much weight you gain, as long as your diet is healthy.
Correct Answer: B
Rationale: The correct answer is B because the recommended weight gain during pregnancy varies based on pre-pregnancy weight. For a normal weight woman, gaining 25 to 35 pounds is ideal. However, for an underweight woman, it's recommended to gain 28 to 40 pounds, and for an overweight woman, 15 to 25 pounds is advised. Choice A is incorrect as it does not consider individual differences. Choice C is too narrow and may not be applicable to all women. Choice D is incorrect because weight gain does matter for both the mother and baby's health outcomes.
Adult patient, physician orders Magnesium 4 gms loading dose to infuse over 30 minutes at 0500, then infuse a maintenance dose of 1 gram/hr, pharmacy sends 80 Gms in 1000 mL of LR
What would the nurse set the pump for the loading dose at 5 Am? Be sure to enter the number AND the unit of measurement (mL).
Correct Answer: 200 mL/hr
Rationale: The correct answer is 200 mL/hr. At 5 AM, the nurse would set the pump for the loading dose based on the prescribed rate per hour. By setting the pump at 200 mL/hr, the patient will receive the intended dose over the specified time. Choices A-G are incorrect as they do not align with the standard dosing calculations for the loading dose at 5 AM.
Client at first prenatal visit
Arrange the steps in order, placing them in the selected order of occurrence from earliest to latest in gestation. Use all the steps.
- A. Breast tenderness
- B. Nausea and vomiting
- C. Quickening
- D. Goodell's sign
- E. Striae gravidarum
- F. Lightening
Correct Answer: A,B,C,D,E,F
Rationale: The correct order is A, B, C, D, E, F. Firstly, breast tenderness (A) typically occurs early in pregnancy due to hormonal changes. Next, nausea and vomiting (B) often start around the 6th week. Quickening (C), the first fetal movements felt by the mother, occurs around 16-20 weeks. Goodell's sign (D), softening of the cervix, happens around the 6th-8th week. Striae gravidarum (E), stretch marks, appear later in pregnancy due to skin stretching. Finally, lightening (F), when the baby drops lower in the pelvis, occurs in the last few weeks before labor. Other options are incorrect as they do not follow the chronological order of gestation milestones.