Nokea
Which pregnant client should the nurse encourage to undergo hepatitis B testing?
- A. A client with a history of cigarette smoking
- B. A client who is a health care worker
- C. A client who emigrated in the past year from Haiti
- D. A client who was recently exposed to Haemophilus influenzae
Correct Answer: C
Rationale: Clients from high-prevalence areas like Haiti are at higher risk for hepatitis B, warranting testing during pregnancy.
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The nurse observes the postpartum multiparous client rubbing her abdomen. When asked if she is having pain, the client says, “It feels like menstrual cramps.” Which intervention should the nurse implement?
- A. Offer a warm blanket for her to place on her abdomen.
- B. Encourage her to lie on her stomach until the cramps stop.
- C. Instruct the client to avoid ambulation while having pain.
- D. Check her lochia flow; pain sometimes precedes hemorrhage.
Correct Answer: B
Rationale: Heat application to the abdomen should be avoided; it may cause uterine muscle relaxation. Multiparous women frequently experience intermittent uterine contractions called afterpains. Lying in a prone position applies pressure to the uterus, stimulating continuous uterine contraction. When the uterus maintains a state of contraction, the afterpains will cease. Ambulation has been shown to decrease muscle pain and should not be avoided. Afterpains are not a symptom of potential postpartum hemorrhage.
The postpartum client, who had a forceps-assisted vaginal birth 4 hours ago, tells the nurse that she is having continuing perineal pain rated at 7 out of 10 and rectal pressure. An oral analgesic was given and ice applied to the perineum earlier. What should the nurse do now?
- A. Call the HCP to report the pain
- B. Closely reinspect the perineum
- C. Help her out of bed to ambulate
- D. Administer a stool softener
Correct Answer: B
Rationale: Reexamination of the perineum should be completed before calling the HCP to report the pain level. A forceps-assisted delivery can increase the risk of hematoma development. Rectal pressure and perineal pain can indicate a hematoma in the posterior vaginal wall. The nurse should closely examine the perineum and the vaginal introitus for ecchymosis and a bulging mass. Ambulation would not help the perineal pain. A stool softener would be appropriate to avoid constipation but would not help the immediate problem.
Which assessment finding best indicates the presence of this condition?
- A. Painful blisters on the labia
- B. Heavy, grayish white discharge
- C. Milky white discharge that smells like fish
- D. Thick, white, curdlike vaginal discharge
Correct Answer: B
Rationale: Chlamydia often presents with heavy, grayish-white discharge, unlike the other options, which suggest different infections.
The laboring client is requesting IV pain medication instead of epidural anesthesia. The nurse determines that which factor would most definitely contraindicate the administration of nalbuphine hydrochloride?
- A. Completely dilated and 100 percent effaced
- B. Fetal heart rate (FHR) of 120 beats per minute
- C. Reassuring FHR variability and accelerations
- D. Variable decelerations with reassuring FHR
Correct Answer: A
Rationale: Systemic medications, such as nalbuphine hydrochloride (Nubain), should not be administered when advanced dilation is present (transition stage of labor) because its use can lead to respiratory depression if given too close to the time of delivery. An FHR of 120 bpm is within normal parameters of 120 to 160 bpm. Reassuring FHR variability and accelerations are interpreted as adequate placental oxygenation and do not contraindicate administration of nalbuphine hydrochloride. If mild variable decelerations are present but the FHR pattern remains reassuring, nalbuphine hydrochloride can still be administered.
The oncoming shift nurse assesses the fundus of the postpartum client 6 hours after a vaginal birth and finds that it is firm. When the nurse then assists the client out of bed for the first time, blood begins to run down the client’s leg. Which action by the nurse in response to the client’s bleeding is correct?
- A. Explain that extra bleeding can occur with initial standing
- B. Immediately assist the client back into bed
- C. Push the emergency call light in the room
- D. Call the HCP to report this increased bleeding
Correct Answer: A
Rationale: Lochia normally pools in the vagina when the postpartum client remains in a recumbent position for any length of time. When the client then stands, gravity causes the blood to flow out. As long as the nurse knows the fundus is firm and not bleeding, a simple explanation to the client is all that is required. There is no reason to return the client to bed; the fundus is firm. There is no reason to push the emergency call light. Increased bleeding is an expected response when standing for the first time. There is no reason to call the HCP.