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While assessing the fundus of a multiparous client 36 hours after delivery of a term neonate, the nurse notes a separation of the abdominal muscles. What action should the nurse take based on this assessment?
- A. Notify the health care provider of the separation.
- B. Discuss with the client that no further action is needed.
- C. Demonstrate exercises involving head and shoulder lifting.
- D. Refer the client to a surgeon for surgical repair after 6 weeks postpartum.
Correct Answer: C
Rationale: Diastasis recti is managed with specific exercises like head and shoulder lifts to strengthen abdominal muscles.
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As the nurse enters the room of a newly admitted primigravid client diagnosed with severe preeclampsia, the client begins to experience a seizure. Which of the following should the nurse do first?
- A. Insert an airway to improve oxygenation.
- B. Note the time when the seizure begins and ends.
- C. Call for immediate assistance.
- D. Turn the client to her left side.
Correct Answer: D
Rationale: Turning the client to her left side helps maintain airway patency and prevents aspiration.
When developing the teaching plan for a primigravid client at 30 weeks' gestation diagnosed with mild preeclampsia who is being treated at home, which of the following would the nurse identify as the most appropriate client-centered goal?
- A. Return visit to the prenatal clinic in approximately 4 weeks.
- B. Decreased edema after 1 week of a low-protein, low-fiber diet.
- C. Bed rest on the left side during the day, with bathroom privileges.
- D. Immediate reporting of adverse reactions to magnesium sulfate therapy.
Correct Answer: C
Rationale: Bed rest on the left side enhances placental perfusion and reduces blood pressure.
At 38 weeks' gestation, a primigravid client with poorly controlled diabetes and severe preeclampsia is admitted for a cesarean delivery. The nurse explains to the client that delivery helps to prevent which of the following?
- A. Neonatal hyperbilirubinemia.
- B. Congenital anomalies.
- C. Perinatal asphyxia.
- D. Stillbirth.
Correct Answer: D
Rationale: Delivery helps prevent stillbirth in high-risk pregnancies.
The nurse is developing a plan of care for a neonate who is to undergo gastroschisis surgery. What should be included? Select all that apply.
- A. Prevention of hypothermia.
- B. Maintenance of fluid and electrolyte balance.
- C. Provision of time for parental bonding.
- D. Prevention of infection.
- E. Providing developmental care.
Correct Answer: A,B,C,D,E
Rationale: All options are critical components of care for a neonate with gastroschisis to ensure optimal outcomes before and after surgery.
A woman who has delivered a healthy newborn is being discharged. As a part of the discharge teaching, the nurse should instruct the client to observe vaginal discharge for postpartum hemorrhage and notify the healthcare provider about?
- A. Bleeding that becomes lighter each day.
- B. Clots the size of golf balls.
- C. Saturating a pad in an hour.
- D. Lochia that last longer than 1 week.
Correct Answer: C
Rationale: Saturating a pad in an hour indicates excessive bleeding.