Question 6051)
The nurse is planning care for a newborn of a mother with diabetes mellitus. What is the priority nursing consideration for this newborn?
A. Developmental delays because of excessive size
B. Maintaining safety because of low blood glucose levels
C. Choking because of impaired suck and swallow reflexes
D. Elevated body temperature because of excess fat and glycogen
Answer: B
Explanation: The newborn of a diabetic mother is at risk for hypoglycemia, so maintaining safety because of low blood glucose levels would be a priority. The newborn would also be at risk for hyperbilirubinemia, respiratory distress, hypocalcemia and congenital anomalies. Developmental delays, choking and an elevated body temperature are not expected problems.
Question 6052)
Rho(D) immune globulin is prescribed for a client after delivery and the nurse provides information to the client about the purpose of the medication. The nurse determines that the woman understands the purpose if the woman states that it will protect her next baby from which condition?
A. Having Rh-positive blood
B. Developing a rubella infection
C. Developing physiological jaundice
D. Being affected by Rh incompatibility
Answer: D
Explanation: Rh incompatibility can occur when an Rh-negative mother becomes sensitized to the Rh antigen. Sensitization may develop when an Rh-negative woman becomes pregnant with a fetus who is Rh positive. During pregnancy and at delivery, some of the fetus's Rh-positive blood can enter the maternal circulation, causing the mother's immune system to form antibodies against Rh-positive blood. Administration of Rho(D) immune globulin prevents the mother from developing antibodies against Rh-positive blood by providing passive antibody protection against the Rh antigen.
Question 6053)
The nurse is monitoring a postpartum client who received epidural anesthesia for delivery for the presence of a vulvar hematoma. Which assessment findings would best indicate the presence of a hematoma?
A. Change in vital signs
B. Signs of heavy bruising
C. Complaints of intense pain
D. Complaints of tearing sensation
Answer: A
Explanation: Because the client has had epidural anesthesia and is anesthetized, she cannot feel pain, pressure or tearing sensation. Changes in vital signs indicate hypovolemia in an anesthetized postpartum client with vulvar hematoma.
Question 6054)
The nurse is providing instructions about measures to prevent postpartum mastitis to a client who is breastfeeding her newborn. Which client statement would indicate a need for further instruction?
A. "I should breastfeed every 2 to 3 hours."
B. "I should change the breast pads frequently."
C. "I should wash my hands well before breastfeeding."
D. "I should wash my nipples daily with soap and water."
Answer: D
Explanation: Mastitis is inflammation of the breast as a result of infection. It generally is caused by an organism that enters through an injured area of the nipples, such as a crack or blister. Measures to prevent the development of mastitis include changing nursing pads when they are wet and avoiding continuous pressure on the breasts. Soap is drying and could lead to cracking of the nipples and the client should be instructed to avoid using soap on the nipples. The mother is taught about the importance of hand washing and that she should breastfeed every 2 to 3 hours.
Question 6055)
The nurse is monitoring a client in the immediate postpartum period for signs of hemorrhage. Which sign if noted would be an early sign of excessive blood loss?
A. A temperature of 100.4 degree F (38 degree C)
B. An increase in the pulse rate from 88 to 102 beats/minute
C. A blood pressure change from 130/88 to 124/80 mm Hg
D. An increase in the respiratory rate from 18 to 22 breaths/minute
Answer: B
Explanation: During the fourth stage of labor, the maternal blood pressure, pulse, and respiration should be checked every 15 minutes during the first hour. An increasing pulse is an early sign of excessive blood loss because the heart pumps faster to compensate for reduced blood volume. A slight increase in temperature is normal. The blood pressure decreases as the blood volume diminishes, but a decreased blood pressure would not be the earliest sign of hemorrhage. The respiratory rate is slightly increased from normal.
Question 6056)
The nurse is assessing a client in the fourth stage of labor and notes that the fundus in firm, but that bleeding is excessive. Which should be the initial nursing action?
A. Record the findigs.
B. Massage the fundus.
C. Notify the health care provider.
D. Place the client in Trendelenburg's position.
Answer: C
Explanation: If bleeding is excessive, the cause may be laceration of the cervix or birth canal. Massaging the fundus if it is firm would not assist in controlling the bleeding. Trendelenburg's position should be avoided because it may interfere with cardiac and respiratory function. Although the nurse would record the findings, the initial nursing action would be to notify the HCP.
Question 6057)
The nurse is monitoring the amount of lochia drainage in a client who is 2 hours postpartum and notes that the client has saturated a perineal pad in 15 minutes. How should the nurse respond to this finding initially?
A. Document the finding.
B. Encourage the client to ambulate.
C. Encourage the client to increase fluid intake
D. Contact the health care provider and inform the HCP of this finding.
Answer: D Explanation: Lochia is the discharge from the uterus in the postpartum period, it consists of blood from the vessels of the placental site and debris from the decidua. The following can be used as a guide to determine the amount of flow:scant less than 2.5 cm(<1 inch) on menstrual pad in 1 hour, light less than 10 cm (<4 inches) on menstrual pad in 1 hour, moderate less than 15 cm (<6 inches) on menstrual pad in 1 hour, heavy saturated menstrual pad in 1 hour, excessive menstrual pad saturated in 15 minutes. If the client is experiencing excessive bleeding, the nurse should contact the HCP in the event that postpartum hemorrhage is occurring. It may be appropriate to encourage increased fluid intake, but this is not the initial action. It is not appropriate to encourage ambulation at this time. Documentation should occur once the client has been stabilized.
Question 6058)
The nurse is caring for four 1-day postpartum clients. Which client assessment requires the need for follow-up?
A. The client with mild after pains
B. The client with a pulse rate of 60 beats/minute
C. The client with colostrum discharge from both breasts D. The client with lochia that is red and has a foul smelling odor
Answer: D
Explanation: Lochia, the discharge present after birth, is red for the first 1 to 3 days and gradually decreases in amount. Normal lochia has a fleshy odor or an odor similar to menstrual flow. Foul smelling or purulent lochia usually indicates infection, and these findings are not normal. The other options are normal findings for a 1-day postpartum client.
Question 6059)
The postpartum nurse is providing instructions to a client after birth of a healthy newborn. Which time frame should the nurse relay to the client regarding the return of bowel function?
A. 3 days postpartum
B. 7 days postpartum
C. On the day of birth
D. Within 2 weeks postpartum
Answer: A
Explanation: After birth, the nurse should auscultate the client's abdomen in all 4 quadrants to determine the return of bowel sounds. Normal bowel elimination usually returns 2 to 3 days postpartum. Surgery, anesthesia and the use of opioids and pain control agents also contribute to the longer period of altered bowel functions.
Question 6060)
The postpartum nurse is taking the vital signs of a client who delivered a healthy newborn 4 hours ago. The nurse notes that the client's temperature is 100.2 degree F. What is the priority nursing action?
A. Document the findings.
B. Retake the temperature in 15 minutes.
C. Notify the health care provider.
D. Increase hydration by encouraging oral fluids.
Answer: D
Explanation: The client's temperature should be taken every 4 hours while she is awake. Temperatures up to 100.4 degree F in the first 24 hours after birth often are related to the dehydrating effects of labor. The appropriate action is to increase hydration by encouraging oral fluids, which should bring the temperature to a normal reading. Although the nurse also would document the findings, the appropriate action would be to increase hydration. Taking the temperature in another 15 minutes is an unnecessary action. Contacting the HCP is not necessary.
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