Nokea
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. Saturating two perineal pads per hour.
- C. Pulse rate of 56 bpm.
- D. Soft, spongy fundus.
Correct Answer: C
Rationale: A pulse rate of 56 bpm is a normal finding for a primigravida client who is 12 hours postpartum. Bradycardia (pulse rate 50-70 bpm) can be a normal postpartum occurrence due to increased stroke volume and decreased cardiac output after delivery. Unilateral lower leg pain and saturating two perineal pads per hour are not normal findings and require further assessment. A soft, spongy fundus could indicate uterine atony, which is abnormal postpartum.
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An expectant father tells the LPN/LVN he fears that his wife 'is losing her mind.' He states she is constantly rubbing her abdomen and talking to the baby, and that she actually reprimands the baby when it moves too much. What recommendation should the nurse make to this expectant father?
- A. Reassure him that these are normal reactions to pregnancy and suggest that he discuss his concerns with the childbirth education nurse.
- B. Help him understand that his wife is experiencing normal maternal behaviors and bonding with the baby, and reassure him that these actions are positive.
- C. Ask him to observe his wife's behavior carefully for the next few weeks and report any similar behavior to the nurse at the next prenatal visit.
- D. Let him know that these behaviors are part of normal maternal-fetal bonding which occur once the mother feels fetal movement.
Correct Answer: D
Rationale: The father's concerns about his wife's behaviors can be addressed by explaining that behaviors like talking to the baby and responding to fetal movements are part of normal maternal-fetal bonding. These actions indicate that the mother is connecting with the baby and are positive signs of a healthy pregnancy. The nurse should reassure the father that these behaviors are common and beneficial for the mother-baby relationship during pregnancy.
The client at 10 weeks' gestation is palpated with the fundus at 3 fingerbreadths above the pubic symphysis. The client reports nausea, vomiting, and scant dark brown vaginal discharge. What action should the nurse take?
- A. Collect a urine sample for urinalysis.
- B. Measure vital signs.
- C. Recommend bed rest.
- D. Obtain human chorionic gonadotropin levels.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
At 14-weeks gestation, a client arrives at the Emergency Center complaining of a dull pain in the right lower quadrant of her abdomen. The LPN/LVN obtains a blood sample and initiates an IV. Thirty minutes after admission, the client reports feeling a sharp abdominal pain and shoulder pain. Assessment findings include diaphoresis, a heart rate of 120 beats/minute, and a blood pressure of 86/48. Which action should the nurse implement next?
- A. Check the hematocrit results.
- B. Administer pain medication.
- C. Increase the rate of IV fluids.
- D. Monitor the client for contractions.
Correct Answer: C
Rationale: The client's symptoms suggest hypovolemic shock, possibly due to an ectopic pregnancy. Increasing IV fluids is crucial to stabilize the client by improving blood pressure and perfusion. This intervention helps address the underlying issue of hypovolemia and supports the client's hemodynamic status, which takes priority in this emergent situation.
A mother who is breastfeeding her baby receives instructions from the nurse. Which instruction is most effective to prevent nipple soreness?
- A. Wear a cotton bra.
- B. Increase nursing time gradually.
- C. Correctly place the infant on the breast.
- D. Manually express a small amount of milk before nursing.
Correct Answer: C
Rationale: The most effective instruction to prevent nipple soreness when breastfeeding is to correctly place the infant on the breast. Proper latch-on techniques ensure that the baby is properly positioned, reducing the risk of nipple soreness. When the baby is positioned correctly, they can nurse effectively without causing discomfort to the mother.
During a newborn assessment, which symptom would indicate respiratory distress if present in a newborn?
- A. Flaring of the nares.
- B. Shallow and irregular respirations.
- C. Respiratory rate of 50 breaths per minute.
- D. Abdominal breathing with synchronous chest movement.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.