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Which postpartum client requires further assessment?
- A. G1P1 with class II heart disease and complains of frequent coughing and has crackles
- B. G3P2 post c/s client who has active herpes on the labia
- C. G4P4 who had 4 saturated pads during the last 12 hours
- D. G2P2 diabetic whose fasting blood sugar is 100
Correct Answer: C
Rationale: The postpartum client who requires further assessment is the G4P4 who had 4 saturated pads during the last 12 hours. This indicates excessive postpartum bleeding, which is abnormal and could potentially be a sign of postpartum hemorrhage. It is crucial to closely monitor and assess the client's vital signs, uterine tone, and overall well-being to prevent any complications related to excessive bleeding. Prompt intervention and medical attention may be necessary to address the postpartum hemorrhage and ensure the client's safety and well-being.
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Magnesium sulfate is given to a pregnant client for which of the following reasons? (Select all that apply) Provide fetal neuroprotection Improve patellar reflexes and increase respiratory efficiency Induction of labor Prevent seizures Stop/decrease uterine contractions The clinical nurse talks with a client about her possible pregnancy. The client has experienced amenorrhea for 2 months, nausea during the day with vomiting every other morning, and breast tenderness. What are these symptoms best described as? Possible signs of pregnancy Positive signs pregnancy Presumptive signs of pregnancy Probable signs of pregnancy The clinic nurse talks with a patient about her possible pregnancy. The patient has experienced amenorrhea for 2 months, nausea during the day with vomiting every other morning, and breast tenderness. She is convinced she is pregnant and is reluctant to pay for a pregnancy test. Which action by the nurse is best?
- A. Agree that these signs usually signal pregnancy so no test is needed.
- B. Delete the order for the pregnancy test and inform the provider.
- C. Explain that these symptoms can be caused by other conditions.
- D. Inform the woman that this is standard procedure and must be done.
Correct Answer: C
Rationale: The best action for the nurse to take in this situation is to explain to the patient that these symptoms can be caused by other conditions besides pregnancy. It is important for the nurse to educate the patient that while these symptoms are commonly associated with pregnancy, they are not definitive signs and can also be attributed to other factors or medical conditions. Encouraging the patient to undergo a pregnancy test can help confirm or rule out pregnancy and provide appropriate care and guidance moving forward.
The nurse is providing instructions to a pregnant client who is scheduled for an amniocentesis. What instruction should the nurse provide?
- A. Strict bed rest is required after the procedure.
- B. Hospitalization is necessary for 24 hours after the procedure.
- C. An informed consent needs to be signed before the procedure.
- D. A fever is expected after the procedure because of the trauma to the abdomen.
Correct Answer: C
Rationale: Informed consent is essential before an invasive procedure like amniocentesis. Monitoring post-procedure symptoms is also crucial.
Whose theoretical model describes how clinical judgment evolves with experience?
- A. Benner
- B. Tanner
- C. Lasater
- D. Nightingale
Correct Answer: A
Rationale: Patricia Benner developed the theoretical model known as the Novice to Expert Theory, which describes how clinical judgment evolves with experience. According to this theory, individuals progress through five levels of proficiency in a skill: novice, advanced beginner, competent, proficient, and expert. Benner's model emphasizes the importance of experiential learning and highlights how nurses develop expertise over time through practical experience and reflection.
The nurse is caring for a client who just had a cesarean delivery. What is the priority nursing action?
- A. Assess the surgical site.
- B. Monitor for signs of infection.
- C. Assess the uterine fundus for firmness.
- D. Encourage early ambulation.
Correct Answer: C
Rationale: Assessing fundal firmness helps detect uterine atony and prevent postpartum hemorrhage after delivery.
A new mother states that her infant must be cold because the baby's head and feet are blue? The nurse should explain that this is a common and temporary condition called:
- A. Acrocyanosis
- B. Vernix caseosa
- C. Erythema neonatorum
- D. Harlequin color
Correct Answer: A
Rationale: Acrocyanosis is a common and benign condition in newborn infants characterized by temporary blueness or cyanosis of the hands, feet, and sometimes the face. This blueness is caused by the temporary constriction of blood vessels in those areas, resulting in reduced blood flow and less oxygen reaching the skin. Acrocyanosis typically resolves on its own and does not indicate any serious health concerns in newborns. It is important for healthcare providers to reassure parents that acrocyanosis is a normal phenomenon in newborns and does not require treatment.