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Which physical assessment data should the nurse consider a normal finding for a primigravida client who is 12 hours postpartum?
- A. Unilateral lower leg pain.
- B. Soft, spongy fundus
- C. Saturating two perineal pads per hour.
- D. Pulse rate of 56 beats/minute
Correct Answer: D
Rationale: A pulse rate of 56 beats/minute is within the normal range for a resting postpartum client. The other options indicate potential complications like DVT, uterine atony, or excessive bleeding.
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What instruction is most important for the nurse to provide a client in the first trimester of pregnancy who is experiencing nausea?
- A. Avoid alcohol, caffeine, and smoking.
- B. Eliminate between meal snacks
- C. Practice relaxation techniques when the nausea first begins
- D. Increase intake of fluids to 3 quarts daily
Correct Answer: C
Rationale: Relaxation techniques like deep breathing can help manage nausea, especially if triggered by stress or anxiety, making it the most effective immediate intervention.
The healthcare provider prescribes magnesium sulfate 6 grams intravenously (IV) to be infused over 20 minutes for client with preterm labor. The IV bag contains magnesium sulfate 20 grams in dextrose 5% in water 500 mL. How many mL/hour should the nurse set the infusion pump? (Enter numerical value only.)
Correct Answer: 450
Rationale: To deliver 6 grams over 20 minutes from a solution of 20 grams in 500 mL, the concentration is 25 mL/g. Thus, 6 grams requires 150 mL over 20 min, which is (150 mL / 20 min) x 60 = 450 mL/hour.
What is the most important assessment for the nurse to conduct following the administration of epidural anesthesia to a client who is at 40-weeks gestation?
- A. Level of pain sensation.
- B. Variability of fetal heart rate
- C. Maternal blood pressure
- D. Station of presenting part
Correct Answer: C
Rationale: Epidural anesthesia can cause a sudden drop in maternal blood pressure, which may affect placental perfusion, making blood pressure monitoring the priority.
A 25-year-old client who had a severe postpartum hemorrhage following the vaginal birth of twins is transferred to the postpartum unit. The nurse knows that assessment for what complication has the highest priority for this client?
- A. Placenta accreta
- B. Hard, painful uterine afterpains.
- C. Postpartum psychosis.
- D. Disseminated intravascular coagulation
Correct Answer: D
Rationale: Severe postpartum hemorrhage increases the risk of disseminated intravascular coagulation (DIC), a life-threatening condition requiring urgent assessment.
The nurse examines a client who is admitted in active labor and determines the cervix is 3 cm dilated 50% effaced, and the presenting part is at 0 station. An hour later. she tells the nurse that she wants to go to the bathroom. Which action should the nurse implement first?
- A. Review the fetal heart rate pattern
- B. Check the pH of the vaginal fluid
- C. Determine cervical dilation.
- D. Palpate the client's bladder
Correct Answer: D
Rationale: A desire to use the bathroom may indicate a full bladder, which can impede labor progress. Palpating the bladder is the priority to assess this.